Steve Jobs was referenced several times during the recent State of the Union address.  Healthcare was conspicuously absent from the speech, for a variety of reasons.  What might Steve thought of electronic medical records?  I would imagine he had some thoughts on the healthcare system, having unfortunately needed to access it during his illness.  Perhaps we will eventually learn what he thought of it.  However, his experience was almost certainly far smoother than an average person’s, given who he was.

Apple products are known for excellent function and design simplicity.  Would an Apple-EMR look anything like the presently available products?  Probably not.  Had he watched a surgeon (as I once did) fumble for 45 minutes trying to put in orders and notes for a procedure that took 30 minutes, his designers would likely receive a profanity-laden tirade.

The trouble with most EMRs is that they are written by techies, and are focused on capturing a large amount of extraneous data that has little to do with the overall care at hand.  Healthcare is a complex area that is made up of many fairly simple components.  The current generation of EMRs are overly complex and have not been implemented because practitioners or consumers (patients) demand or require them, but because government incentives (and soon, coercion) have been required to force their adoption by a sector that does not have a true need for the product.

Consider the quick-service restaurant sector.  Their version of the EMR is ubiquitous and necessary in order to serve customers and compete.  It enhances the operator-customer experience.  Here’s how it would look if a current EMR was adopted for restaurant use:

(From a recent exchange at McDonald’s.  Yes, even doctors occasionally eat there.)

Me:  “I’d like a Southern Chicken Sandwich.”

Staff:  “Your height and weight please?”

Me:  “Six feet four, 205 lbs.”

Staff: [narrows eyes in disbelief]

Staff:  “Any pets in the home?”

Me:  “What does this have to do with my order?”

Staff:  “What color is your couch?”

Me:  “Well, I’m still trying to clean a butter stain, and the cat  made a mess on it.  Let’s call it  beige-to-yellow.”

You get the point.  This sort of data collection erodes the user experience and impedes the purpose for which the system is supposed to serve.

Future EMRs will solve these problems.  It is not that the data is completely useless, but most is unnecessary and collecting it in the current fashion saps productivity and leads to all sorts of unintended consequences.  For example, specialists may scan, skip or ignore most of the pre-generated information from EMR referrals, focusing only on the issue for which they are being consulted.  Copy-and-paste can lead to absurd rounds of the children’s “Telephone Game”.  (Amputees with normal pulses in the limb, etc.)

Healthcare will eventually have full, well-designed EMR adoption.  But getting there will take a few more software generations.  Here are three easy ideas just by borrowing from what already works in tech.

1. Touchscreen navigation:  Akin to the old lightpen (precursor to the mouse), this makes it quick and easy to enter information.  Hand sanitizer at every workstation will help with germ fears.
2. Smart Software:  If Amazon knows what products you likely want, the EMR should know your order sets and what medications you typically prescribe.  An orthopod shouldn’t sift through a hundred obscure medications to select antibiotics and pain meds, and to put in his standard orders.
3. Simplify documentation:  When patients are seen for a specific problem, notes only need a small amount of information.  Extraneous details can be captured at the initial visit and any changes made later.  Put it on the sidebar of the page, so it is visible but does not crowd out the important information.

This is only a start, and larger organizations should lead the way as EMR costs are unfriendly for most offices.  Community physicians could use web-based EMRs hosted at the local hospital (free if on staff, perhaps subscription-based otherwise).

The U.K.’s scrapping of their EMR project should be considered carefully.  It’s high time for someone with a touch of Steve Jobs’ vision to create an EMR here so good that it won’t need carrots or sticks to be adopted.

Related articles

• Stimulus Funds Helped Some EMR Companies (emrelectronicmedicalrecords.com)

Europe’s debt and currency issues were briefly pushed aside when France recently announced that about 30,000 women should have removal of substandard silicone breast implants.   Manufactured by Poly Implant Prothese SA (PIP), these devices may have a higher than normal rupture rate, and the company has been accused of using inferior, non medical-grade silicone.

Silicone breast implants have had a convoluted history in the United States, and were taken off the market for cosmetic use from 1992-2006.  They were reintroduced with a new gel design and enhanced documentation and follow-up recommendations.  Since silicone breast implants tend to touch off fireworks whenever they are in the news, here are a few points for Americans to keep in mind.

1)       These silicone implants are not the ones used in the U.S.  Ours are different, and the FDA warned the French company of manufacturing problems back in 2000.

2)      The implants haven’t yet been proven to cause serious health effects.  It will take time until experts can determine what, if any problems will be attributed to the inferior materials.

3)      The potential safety issue is not the use of silicone in breast implants, but the use of non-medical grade material in the French devices.

Five years following the reintroduction of silicone breast implants in the U.S., an FDA review deemed them safe for use.  The association with a very rare form of lymphoma was noted.

The French case says more on the issue of proper government oversight of product safety than it does about the safety of properly-designed silicone breast implants.  The FDA deserves credit for their report regarding PIP’s manufacturing problems.  However, there are many questions that have yet to be answered as to why French authorities took so long to discover and act on the problem.

Related articles

• Despite Risks, Silicone Breast Implants Still Considered Safe (bellasugar.com)
• Breast implant scandal firm ‘used same faulty silicone in prosthetic testicles’ (mirror.co.uk)

The resignation of Don Berwick as director of CMS didn’t seem to get major press coverage. Dr. Berwick was appointed to lead CMS in July 2010 when Congress was in recess, and thus needed Congressional approval to serve beyond 2011. He quickly became a punching bag for some lawmakers, who attacked his purported admiration of the British National Health Service. He was also subjected to criticism for a prior statement on health care rationing. I previously commented on his exact statement here, and noted that the criticism appeared to distort the factual record.

Realizing that the Senate would not confirm him, he has stepped down.

By all accounts Dr. Berwick is an upstanding physician with a solid reputation. And the problems that he so accurately noted will not be resolved by his resignation. The position of CMS Director increases in importance every day as the government debt pile grows larger, fueled in large part by healthcare expenditures. This problem will not be solved without co-operation from both political parties.
The fact remains that the government has simply promised much more health care than it is capable of providing, and some method of matching these promises with the forces of reality will take place. This can be through price rationing, non-price rationing, large tax increases, or some combination of the three. But what has been happening will not continue indefinitely.

Dr. Berwick may have been criticized for speaking the truth on this matter, but he is no different from a new CFO brought in to aid a struggling business. When the business owner later receives a report saying “Something major has to change or you are headed for bankruptcy.” Should he fire the messenger?

Regardless of who leads CMS, the mathematical problems with Medicare and Medicaid will not go away. Best of luck to the next director!

Related articles

• Obama’s Pick to Head Medicare and Medicaid Resigns Post – Ocala (ocala.com)
• Statement On Dr. Donald Berwick’s Departure As Administrator Of The Centers For Medicare And Medicaid Services (medicalnewstoday.com)
• US Medicare chief to resign after political standoff (trust.org)
• A Vacancy That Needs to Be Filled (nytimes.com)

Amateur buttock enhancers are fairly prominent in the region, where there is higher than average demand for all sorts of cosmetic procedures.  Buttock shaping is a popular procedure, and is fun and fairly straightforward to do.  Properly selected patients tend to do well and satisfaction rates are high.

Perhaps due to the economy, or to ignorance, some people allow lay-practitioners (some may be partially medically trained) to inject substances into their buttocks, hoping to get the same effect as a proper cosmetic surgery.  There are two things to keep in mind regarding this concept:

1. There are only two medically legitimate ways (in this country) to reliably augment the buttocks:  with silicone implants or with fat grafting.

   Silicone implants are less commonly done since there are generally higher rates of complications than with fat grafting.  They can be appropriate for thin patients who do not have enough donor area fat.  But in general, fat grafting is the preferred procedure and makes up the majority of buttock enhancing procedures.

2. Home-improvement substances such as caulk, silicone, Fix-a-Flat and cement (to  name a few) are not supposed to be put in your body.

   Though this should be obvious, not everyone realizes it.  These substances are not designed for medical use, and can have all sorts of complications.  There can be infection, hardening or destruction of tissue, and embolization (stuff entering blood vessels and clogging up the lungs or other organs).  Any of these events can lead to irreparable tissue problems, disability, or death.

Some victims may believe that they are under the care of real medical professionals, (though I don’t know too many colleagues who perform procedures in basements or hotels).  Others may not think these substances are harmful, or believe they are legitimate in other countries but not in the U.S. (they’re not).

Here is a brief list of similar incidents:

Miami, June 2008

Miami, September 2010

Las Vegas, April 2011

Related articles

• ‘Buttock cement fixer’s bum deal’ (thesun.co.uk)
• Buttock enhancement is ‘the new boob job’ (mya.co.uk)
• Illicit silicone injections risky, even deadly: doctors (ctv.ca)

Recent developments, arguably resulting from government over-experimentation in health care; have led to physician pseudo-shortages, mostly in the area of primary care.  This is not the typical “creative destruction” that is a healthy part of market upheaval, since this is the result of policies that fly in the face of economic reality and human nature.

As a partial solution, several initiatives are being pursued, including the expansion of non-physician providers.  Seizing upon this opportunity, there has been a tendency for some non-physician providers to obtain Ph.D. level degrees, and use the term “doctor” in health-care settings.  There is a substantial amount of pressure to allow these practitioners to practice autonomously, as de-facto primary-care providers (and likely soon, in other specialties).  Issues of patient confusion and turf battles with doctors of the medical-school graduate sort aside, the more important question is, “Was Flexner wrong?”

Primary-care is a challenging field.  Day after office day goes by; with three or four visits per hour (doing any less in most insurance-based practices makes it nigh-impossible to keep the office lights on).   Most visits are for simple issues.  Every now and then, there’s the snake in the grass.  Its the young man with blurry vision, who is actually having a carotid dissection.  Its the ‘breast cellulitis’ that is actually an inflammatory carcinoma.  Its the vague intestinal problem that is actually a colon cancer.  Experienced primary-care physicians sometimes miss these diagnoses.  And it is a fact that physician extenders undergo far shorter education and training periods.

Allowing non-physicians to practice primary-care without supervision circumvents the traditional medical education system, even if sanctioned by government entities to address the physician pseudo-shortage.  The public should clearly understand one thing:  these folks are practicing medicine.

Rigorous evidence does not yet exist to satisfy the arguments of those on either side of the debate regarding safety of unsupervised non-physician medical care.  Some believe that this care is equivalent to that given by traditionally trained primary-care physicians.  A large amount of anecdotal evidence suggests that it is not.  But to think that non-physicians, even those with advanced degrees, can do a better job, without anywhere near the same level of training as primary-care physicians, belies common sense.

Displacing primary-care physicians is an almost explicitly stated goal by those seeking to fill the primary-care shortage; or put less charitably, to enter the medical profession via an alternate route.

Consider the 2005 Strategic Plan (in ALL CAPS) from the American College of Nurse Practitioners, and judge for yourself.  Such an expansion stands to roll back a century of educational precedent.

Self-interested arguments are not productive in examining the proper role of non-physicians in providing autonomous, unsupervised care to the American public.  As pointed out by other authors, physicians need to quickly demonstrate to patients the value they offer, and deliver that value as best they can.

What is productive is examining the topic considering each point on its merits.  The question is what type of training is required to safely allow the practice of medicine, and more directly, “Was Flexner wrong?”

Prostate Adenocarcinoma

The U.S. Preventive Services Task Force is at it again.  Health policy watchers will recall 2009, when the panel touched off a firestorm of criticism when it advised that women not undergo routine annual screening mammograms until age 50, and to make individual decisions regarding the risks and benefits of screening mammograms between ages 40-49.

After touching the breasts, and having their hands sharply slapped, they now have tried to finger the prostate.  For the anatomically uninitiated, reaching the prostate requires a more delicate approach.  The group is poised to recommend that screening for prostate specific antigen (PSA) should no longer be performed, challenging a long-accepted paradigm.

It’s possible the average man may shrug and say “Okay so I don’t need to get it checked.  Fine.”   But there will be resistance to the new guidelines, although it is unlikely to rise to the level seen following the mammography recommendation.

The new policy should allow many asymptomatic men to avoid the unneeded workups and all the resulting complications investigating elevated PSA levels.  If adopted on a wide basis, the likely effect on robotic prostate surgery, itself a subject of considerable debate, is likely to be slowing of the adaptation of this expensive, controversial technology.

Panels often face criticism when recommendations differ from popularly held notions of appropriate tests and treatments.   Determining guidelines for a population involves balancing costs against benefits.

It is very difficult to explain the logic and the statistics behind these recommendations to a lay population, who often are skeptical when apparently standard management is altered.  But even professional audiences may let emotion cloud their reactions to new paradigms.

All too often, accusations of rationing and ulterior motives cloud the conclusions, and anecdotal, rather than scientific arguments are used to challenge the new information.

Going forward, there will be more and more study of various types of tests and treatments.  New guidelines will inevitably emerge, replacing the old conventional wisdom.  As always, there will be various degrees of debate, and sometimes resistance.  In order to foster acceptance, panels should present the new information with as much care as was taken to generate it.  Similarly, refutations of panel recommendations should be based on scientific merits rather than emotion or anecdotal arguments.

Related articles

• U.S. Preventive Services Task Force to Say Men Don’t Need Prostate Screenings (blippitt.com)
• Should I get screened for that? (cnn.com)
• Prostate cancer experts bash panel’s PSA test recommendation (cbsnews.com)
• The trouble with prostate cancer tests (cnn.com)

Image via Wikipedia

USA Today recently presented a multi-part series on cosmetic surgery.  The first segment brought attention to the issue of physicians of many specialties diversifying into cosmetic surgery.  I have discussed scope of practice before, and there are pros and cons with regulation of the cosmetic market.  It is important for the general public to understand the due diligence that should be done before choosing a doctor.

But it is also important to acknowledge that there is a lot of self-interest and bias in the statements made on the subject by practitioners in all the relevant fields, including mine.   If legislators ever took the step of placing cosmetic surgery solely within the purview of board-certified plastic surgeons, those surgeons would personally benefit.  But the benefit to consumers would be highly questionable, and would likely not be enough to justify such an extreme step.

A key consideration that gets little attention is that many fields were pioneered by surgeons whose core training was in other areas.  Thoracic and cardiovascular surgery, transplant, hand and plastic surgery, all were developed by surgeons stretching out into new areas.  The obvious difference was that these fields were developed to solve difficult clinical problems, and not due to business considerations.

The next segment of the USA Today series described problems that have resulted from corporate entry into the cosmetic surgery field.  Three firms were profiled, and in the interest of disclosure, I have provided independent-contractor services to one of them.

The general conclusion was that corporate efforts such as intense marketing and utilizing economies of scale is an unfavorable development, and associated with less satisfactory clinical outcomes.  That conclusion is debatable.  What is not debatable is that this type of market activity benefits consumers wishing to obtain equivalent services at much lower prices.  It happens all the time in the retail economy, though the concept is new to this particular segment of the service economy.

MOC  involves meeting certain requirements every few years, culminating in a re-examination at the end of each ten-year cycle.

Keeping up with MOC involves paying fees and completing various tasks purported to keep the physician up-to-date with the latest developments in their field.  The specific tasks vary by specialty.  How this improves existing continuous medical education (CME) programs is not known.  It is known that the MOC process involves substantial time and money.  Meeting the requirements often diverts doctors from clinical practice.  There is minimal evidence that increasing certification requirements improves patient outcomes, affects malpractice statistics, or otherwise impacts any healthcare metric, other than money spent in the MOC effort.

Maintaining competence and knowledge in medicine is important, but MOC does not represent progress in medical education.  Organization against the MOC requirements has begun forming, notably with the website changeboardrecert.com.  Rather than advocating for an elimination of the program, the organization seeks removal of the more onerous MOC criteria, while preserving some of the continuing education elements.

From the site:

“We are all for staying current with medical changes, but the onerous MOC program is no way to achieve this. It’s a money-making juggernaut with scant data to support any benefit for improving patient care and safety or for making one a better physician. And it lacks reasonable financial transparency.”

It is fascinating that the MOC requirements for physicians are increasing, at a time when health reform stands poised to turn much of the American primary care system over to non-physicians.

It remains to be seen if opposition efforts will alter MOC programs, but the resistance highlights the pitfalls that occur when sweeping programs are implemented without evidence that they have any benefit.

Related articles

• ABIM Maintenance of Certification (MOC) internal medicine exam tips (kevinmd.com)

I think the first two minutes of the presentation were fine.   Dr. Caplan outlined the reasons why approximately 6,000 U.S. primary care physicians adopted a concierge model.  For more background on concierge medicine, see a prior post here.  The remainder of the piece presented two arguments against concierge medicine, underlined below and followed with my own respectful disagreement.

Argument 1:  When doctors enter concierge medicine, they remove themselves from the general pool of  primary care providers, leaving more work for the doctors left behind.

I don’t agree, for several reasons.  Doctors have an individual responsibility to their patients, but they do not have (as yet) a system-wide obligation to suffer because of the current business model of private-practice medicine.  Most of those problems are not due to doctors or even insurance companies.  They result from the gradual intrusion of top-down government control over healthcare, beginning in 1965.  This control has now progressed to the point where instead of addressing market failures, government behavior has caused them.  Leaving more work for other physicians is not a valid argument against concierge medicine.

That line is more appropriately applied to resident physicians who slack off during training, leaving more work for their trainee-colleagues.  (This is a cardinal offense in the world of residency).  If doctors are operating private businesses on government-mandated pricing systems, they have little choice but to make other adjustments to keep their businesses viable, since they cannot raise prices.  If a business cannot raise prices when needed, its options to keep itself viable are limited.  One can assume that if market forces were allowed to operate, the value of primary-care office visits would float based upon service, clinical skill, reputation, and management skill (controlling overhead).  I don’t know what a typical primary care office visit should cost, but neither do government price-setters.

Argument 2:  Patients may end up with less quality care, since they will be seeing more physician extenders.

I disagree with this as well.  In many primary care practices, physician extenders have been required to maintain viability even in non-concierge practices.  Furthermore, non-concierge hospital primary care groups with employed physicians already make liberal use of physician extenders.  The “trend to extend” has been driven by many other forces, the least of which is the growth of concierge medicine, itself just now becoming a blip on the national radar.  In some rural areas, unsupervised physician extender primary care practices are already a reality.  Discussing the proper role of physician extenders and whether or not there is a quality difference is itself a large and distinct topic.  Extenders are here to stay, and patients will have less control over whether they see an extender or a physician, especially as health reform plays out.

Concierge medicine may not be perfect, but it represents market forces attempting to assert themselves, now that the centrally-planned model (administered prices) has been strained to its natural breaking point.  We don’t have these sorts of arguments on the price differentiation common in all other service-industries, such as consulting, law, accounting, etc.  Yet in medicine, we seem to feel that price differentiation is somehow inappropriate.  Prof. Caplan does acknowledge longstanding concierge-like models of care, such as executive physicals and specialty clinics.

Virtually all industries have participants targeting low, middle and high market segments. Medicine is not that different, and promoting wide access to good-quality care for all who require it can be done without more top-down control of the system.  If anything, it is that control which has exacerbated the healthcare system’s problems.

Related articles

• ‘Concierge medicine’ a controversial trend in Canada (ctv.ca)
• John Geyman: The Decline Of Primary Care: The Silent Crisis Undermining U.S. Health Care (huffingtonpost.com)

Hampden County, MA

Another hospital system has announced job cuts.  This time, it was Baystate Health System, which announced a reduction of 354 jobs, or 3.5% of its payroll.  The Boston Globe article describes the hospital suffering a $25m shortfall, blamed on lowered state Medicaid support.

Only 169 of the quoted 354 jobs involve flesh-and-blood layoffs, with the balance coming from the elimination of open positions.  Baystate is the latest in a series of medical centers that have trimmed positions in the 3% range.  Each center faces common challenges from the changes likely to come under health reform, but these are superimposed upon the environment particular to the individual entities.

Having spent five tough, but ultimately rewarding years at this particular medical center, I can speculate on two of the issues likely facing Baystate.  The first item is probably more significant, though both are challenging to tackle.

1)       Difficult demographics:   Baystate is located in the Hampden County city of Springfield, tucked out in western Massachusetts.  Its a classic New England locale, but the surrounding population’s economic profile is lower than the rest of the state by a significant margin.  The article notes that 26% of the patients are on Medicaid.  I would term that as accurate or possibly even a low estimate.  According to 2010 data, 17.2% of the county is below the poverty level, which is almost 7% more than the state average.  Per capita and household incomes are both about 27% lower than the state average.  This means that the hospital’s fortunes are tied greatly to what happens to Medicaid funding, and right now that funding is under pressure until (and if) it is raised under health reform

2)      Patient Drain:    There is some drain of area patients to centers in Boston, and occasionally Worcester.  I don’t have exact data, and this phenomenon is not unique to Massachusetts.  But the effect is probably worse in smaller states.  A 90 minute ride to Boston is far easier than a midwesterner driving 10 hours to the Mayo Clinic.  There isn’t good evidence that these centers provide better care except for exotic services that only they provide.  Baystate can do almost (but not quite) everything that Boston can.  It’s a good idea to identify the routine services leaving the area and work on keeping that care local.  Also, those leaving the area for care likely are well insured, and hail from the affluent suburbs.

On the plus side, Baystate is the flagship hospital for the region, and is affiliated with an academic medical center.  It draws from most of the area including the border areas with New York, Vermont, and Connecticut.  It has been well managed and has not been subjected to large financial shocks.

Hospitals can’t do much about regional demographics, and influencing Medicaid funding is difficult.  Managers are thus focusing on the levers that are under their control, namely operations and payroll.  But the challenges faced by hospitals such as Baystate are just a prelude to what may be required once the effects of the health reform legislation start to unfold.

Related articles

• Hospital network cutting 354 positions (boston.com)
• More Hospital Layoffs in Massachusetts and Mergers – Operating Income Funded A Lot of Technology Upgrades – Close To $49 Million (ducknetweb.blogspot.com)