About 15 years ago, when one of my daughters was a hostess at a DC restaurant, Ted Kennedy came in for a private function. My daughter said "Senator, as a registered Massachusetts voter, I welcome you to (name of restaurant)."
"Where's the bah," Ted replied.
He was who he was, and somehow I like that story about him. He will be rolling in encomiums as they lower him down, most undeserved, but somehow I just can't help liking the guy.
The Kennedy/Feingold bill made me and just about every other doctor in the US a slave to paperwork. But real people with real jobs whose employers changed insurance every year suddenly found themselves relieved of the 'pre-existing condition' trap, and people got helped.
He was running against Ray Shamie (R) for reelection some years ago, and during one of their debates, Ted was declaiming on the network of support and intercalated logs that could be rolled, and Shamie interrupted.
"So, that's what you do?" Shamie sneered. "You crank up the democratic machine and just follow the party line?
"You BET I do!" Ted shot back. "That's how things get done in DC! And if you don't know that, you've got no hope of doing anything for the people of Massachusetts if you evah get up theah!"
You gotta love this guy.
I think in the end, Ted got what he wanted publicly and privately, and delivered on what he got paid to do by the people who bought him. Few others in the Senate have done even that. Graft is graft, but honest graft is honest graft.
And that's what Ted did. He was an honest thief, and given the state of the Union, we should have more like him. Senators will get paid. They just won't give quality for the money like Ted did.
Thursday, August 27, 2009
Thursday, August 6, 2009
We're from the home office...
Just a quickie:
Saw a patient today who is from mainland China. He's a researcher. He wants to stay in the US, so he is applying for a green card.
A great deal of the non-US world gets a vaccine as kids. It's called BCG (Bacillus-Calmet-Guerin, approximately). Bacillus CG is another word for Mycobacterium tuberculosis. If you receive this vaccine, your tb skin test (ppd--standing for Purified Protein Derivative) is always positive.
He produced a document from the US State Department saying that, even if you have proof that you had a BCG vaccine, and that you have a chest x-ray that shows no evidence of tb, you WILL NOT receive a green card unless you take INH (Isoniazid) for nine months.
INH can be hepatotoxic. And if you don't take it with supplements of Vitamin B6, you can develop a nasty peripheral neuropathy.
If I have a patient that used to have a negative ppd, and it changes to a positive one, you OFFER a patient six months of INH to lower the possibility of 'late reactive' tuberculosis as they approach old age. You OFFER it to them, and get their informed consent before they take it.
But, thank God, this guy left a totalitarian state and came to the US. Let freedom ring.
Saw a patient today who is from mainland China. He's a researcher. He wants to stay in the US, so he is applying for a green card.
A great deal of the non-US world gets a vaccine as kids. It's called BCG (Bacillus-Calmet-Guerin, approximately). Bacillus CG is another word for Mycobacterium tuberculosis. If you receive this vaccine, your tb skin test (ppd--standing for Purified Protein Derivative) is always positive.
He produced a document from the US State Department saying that, even if you have proof that you had a BCG vaccine, and that you have a chest x-ray that shows no evidence of tb, you WILL NOT receive a green card unless you take INH (Isoniazid) for nine months.
INH can be hepatotoxic. And if you don't take it with supplements of Vitamin B6, you can develop a nasty peripheral neuropathy.
If I have a patient that used to have a negative ppd, and it changes to a positive one, you OFFER a patient six months of INH to lower the possibility of 'late reactive' tuberculosis as they approach old age. You OFFER it to them, and get their informed consent before they take it.
But, thank God, this guy left a totalitarian state and came to the US. Let freedom ring.
Sunday, August 2, 2009
Lewis Mumford
The EMR has been touted as one of the things that can make health care affordable, universal, and of higher quality.
The first question that comes up is: Higher than what?
One would like to think that the methods used by practices that are 'high performing' (take good care of their patients) are reproducible. In order for them to be that, one would have to know what their methods are.
In a study in the Annals of Family Medicine in 2007, looking at such practices, they concluded that "[t]here is no single approach that explains the superior performance of high-performing practices," and that if you could figure out what that common thread was, "[t]he archtypes could prove to be a useful guide to to other practices selecting an overall quality improvement approach (my emphasis)."
So, if you knew what they were doing right (which you don't), maybe that information could be useful to other practices if they were looking to do something besides keep the shit at shoe level.
In the face of that, why are people hooting it up for an EMR? Does it help? The operative governmental line is that it does. I think it's just sexy technology that lets people feel like they're actually doing something.
The position of the Powers That Be is that the EMR improves quality of care for patients. There are a few assumptions on which this is based:
1) Clinical guidelines formulated from 'Evidence Based Medicine' will help physicians practice better medicine.
2) The EMR can help disseminate these guidelines and physicians will then use them.
3) Use of the EMR will then raise the quality of medicine practiced in the United States.
Don't you just love syllogisms?
Let's look at data about guidelines helping physicians practice better medicine:
Archives of Internal Medicine Jan 22; 16(2): 189-97
This is a study looking at what happened when MD's were electronically notified of a diagnosis of depression electronically vs other means:
"There were no differences in the agreement rate or treatments provided across guideline exposure conditions."
In other words, being aware of the guidelines didn't change anything.
Del Med J 2004 Mar 76(3): 111-22
"The Medical Society of Delaware's Uniform Clinical Guidelines are intended to standardize care for diabetes and other conditions. While the guidelines may help to reduce unnecessary duplication and confusion caused by multiple guidelines, this study showed that they have not yet resulted in substantial improvements in quality of care for diabetes."
Inform Prim Care 2006; 14(1): 29-40 ( a TechnoJournal)
Paraphrased, this study was done in the UK to evaluate concordance with Quality Points (clinical guidelines) and the quality of care for patients with strokes. The practices with fewer Quality Points had more adherence to the Royal College of Physicians advice on care for stroke patients. That is, awareness of the clinical guidelines had a negative correlation with patient care.
So: nobody seems to have a good handle on how good physicians do a good job. Maybe clinical guidelines help, maybe not. No one seems to know.
That having been said, why the bejeesus is disseminating those guidelines via an EMR so highly promoted?
I bet it's because people get better care in hospitals. Think?
Med Care Res Rev 2008 Aug; 65(4) 496-513:
"The authors...assess the relationship between hospital EMR use and quality performance...related to 3 clinical conditions: acute myocardial infarction, congestive heart failure, and pneumonia. ...They conclude that there is limited evidence of the relationship between hospital EMR use and quality."
Oopsie. Can't be that. Maybe office care gets better.
Arch Int Med 2007 Jul 9; 167(13): 1400-5
"For 14 of the 17 quality indicators, there was no significant difference in performance between visits with vs without EHR use....As implemented, EHR's were not associated with better quality ambulatory care."
Um--nope. Not that either.
So, where's the beef?
It is, as always, in the money, and the ease by which it can be acquired.
The first step the big insurance carriers took to maintain their profit margin was to make sure that if costs were cut, they were cut at the expense of providers and hospitals, not 'carriers.' They did this by making oversight of health care punitive, not supportive (see previous blog).
Now they'd like to cut the overhead on the information they need to not pay people (or make them give money back), and save themselves a bit more administrative moolah.
How?
Get EMR's everywhere, so the data they now administer will cost them no more than a USB cable.
I practice primary care medicine every day, and have for more years than I care to think about. I listen. When I listen, I find out things. When I find out things, I make diagnoses. When I make diagnoses, people either get better or don't get sick in the first place.
So when people start screaming that the answer to better health care is more technology, let us humbly recall the words of one Lewis Mumford:
"Some of the grotesque miscalculations and misappraisals that have been made in comparing the working efficiency of past ages with the present...[are based on] the blunder of confusing the increased load of equipment and the increased expenditure of energy with the quality of effective work done...The fact is that an elaborate mechanical organization is often a temporary and expensive substitute for an effective social organization."
Logic is adrift.
The first question that comes up is: Higher than what?
One would like to think that the methods used by practices that are 'high performing' (take good care of their patients) are reproducible. In order for them to be that, one would have to know what their methods are.
In a study in the Annals of Family Medicine in 2007, looking at such practices, they concluded that "[t]here is no single approach that explains the superior performance of high-performing practices," and that if you could figure out what that common thread was, "[t]he archtypes could prove to be a useful guide to to other practices selecting an overall quality improvement approach (my emphasis)."
So, if you knew what they were doing right (which you don't), maybe that information could be useful to other practices if they were looking to do something besides keep the shit at shoe level.
In the face of that, why are people hooting it up for an EMR? Does it help? The operative governmental line is that it does. I think it's just sexy technology that lets people feel like they're actually doing something.
The position of the Powers That Be is that the EMR improves quality of care for patients. There are a few assumptions on which this is based:
1) Clinical guidelines formulated from 'Evidence Based Medicine' will help physicians practice better medicine.
2) The EMR can help disseminate these guidelines and physicians will then use them.
3) Use of the EMR will then raise the quality of medicine practiced in the United States.
Don't you just love syllogisms?
Let's look at data about guidelines helping physicians practice better medicine:
Archives of Internal Medicine Jan 22; 16(2): 189-97
This is a study looking at what happened when MD's were electronically notified of a diagnosis of depression electronically vs other means:
"There were no differences in the agreement rate or treatments provided across guideline exposure conditions."
In other words, being aware of the guidelines didn't change anything.
Del Med J 2004 Mar 76(3): 111-22
"The Medical Society of Delaware's Uniform Clinical Guidelines are intended to standardize care for diabetes and other conditions. While the guidelines may help to reduce unnecessary duplication and confusion caused by multiple guidelines, this study showed that they have not yet resulted in substantial improvements in quality of care for diabetes."
Inform Prim Care 2006; 14(1): 29-40 ( a TechnoJournal)
Paraphrased, this study was done in the UK to evaluate concordance with Quality Points (clinical guidelines) and the quality of care for patients with strokes. The practices with fewer Quality Points had more adherence to the Royal College of Physicians advice on care for stroke patients. That is, awareness of the clinical guidelines had a negative correlation with patient care.
So: nobody seems to have a good handle on how good physicians do a good job. Maybe clinical guidelines help, maybe not. No one seems to know.
That having been said, why the bejeesus is disseminating those guidelines via an EMR so highly promoted?
I bet it's because people get better care in hospitals. Think?
Med Care Res Rev 2008 Aug; 65(4) 496-513:
"The authors...assess the relationship between hospital EMR use and quality performance...related to 3 clinical conditions: acute myocardial infarction, congestive heart failure, and pneumonia. ...They conclude that there is limited evidence of the relationship between hospital EMR use and quality."
Oopsie. Can't be that. Maybe office care gets better.
Arch Int Med 2007 Jul 9; 167(13): 1400-5
"For 14 of the 17 quality indicators, there was no significant difference in performance between visits with vs without EHR use....As implemented, EHR's were not associated with better quality ambulatory care."
Um--nope. Not that either.
So, where's the beef?
It is, as always, in the money, and the ease by which it can be acquired.
The first step the big insurance carriers took to maintain their profit margin was to make sure that if costs were cut, they were cut at the expense of providers and hospitals, not 'carriers.' They did this by making oversight of health care punitive, not supportive (see previous blog).
Now they'd like to cut the overhead on the information they need to not pay people (or make them give money back), and save themselves a bit more administrative moolah.
How?
Get EMR's everywhere, so the data they now administer will cost them no more than a USB cable.
I practice primary care medicine every day, and have for more years than I care to think about. I listen. When I listen, I find out things. When I find out things, I make diagnoses. When I make diagnoses, people either get better or don't get sick in the first place.
So when people start screaming that the answer to better health care is more technology, let us humbly recall the words of one Lewis Mumford:
"Some of the grotesque miscalculations and misappraisals that have been made in comparing the working efficiency of past ages with the present...[are based on] the blunder of confusing the increased load of equipment and the increased expenditure of energy with the quality of effective work done...The fact is that an elaborate mechanical organization is often a temporary and expensive substitute for an effective social organization."
Logic is adrift.
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