Archive for July, 2013
On 7/23/13 Laura Landro of the Wall Street Journal published an article about “A Better Digital Diagnosis”. The essence of the story is on-line symptom checkers are available and may be useful to patients. Just input your symptoms, get your diagnosis, call for an appointment, and get your treatment. Sounds good; possibly too good.
Below are listed some good sources for information, some symptom checkers and some software to download to a smart phone. The software is actually intended for health care providers and may have too much jargon for the average person.
However, before you jump in to get a diagnosis for what ails you try a test run. OK, this is not a double blind experiment but worth your time. The idea is to look up the details of a known disease then enter the published symptoms in the symptom checker and see what comes out. You will find a huge variation, often the expected diagnosis does not even show up at all!
For example: plantar faciitis. This is a common disease of the foot caused by inflammation of the connective tissue in the sole of the foot especially causing pain just in front of the heel bone. The striking and often diagnostic symptom is heel pain on first getting out of bed and walking. The pain gets better after a few minutes of walking. It is common in runners and people who spend lots of time standing. Being overweight or wearing hard-sole shoes contributes. As people get older the natural padding of the sole thins which is probably why the problem is common after age 50.
The symptoms were entered into several of the symptom checkers. Esagil seemed to give every diagnosis know to medical science and nothing would narrow down the possibilities — every symptom could be due to syphilis. The Mayo Clinic site required some human thinking. Foot pain showed several areas to read about: after reading the material the diagnosis of plantar faciitis seems to fit.
The diagnosis of plantar faciitis can usually be made by a primary care provider in a flash — it is a common problem. Worrying about whether you have syphilis is a waste of time and a real source of anxiety — if you ask the primary care provider whether you could have syphilis, you can almost count on some testing.
Once you have tested any symptom-checker and understand the limitations they can be helpful. It’s almost like a second opinion about a problem. Discuss the findings with the health care provider early in an office visit — don’t spring the information after the provider makes a plan. Be a team player to prevent being at odds with the provider.
Good sources for medical information:
Evaluate symptoms / differential diagnosis
Smart Phone Apps
- Differential Daignosis by mHealth Labs, LLC
- Differential Diagmosis by Borm Bruckmeier Publishing LLC
- Your Rapid Diagnosis for Android by WWW Machealth
- Differential Diagnosis from the BMJ Group
- Your Rapid Diagnosis by WWW Machealth
- VisualDx by Logical Images
- Common Symptom Guide by Mobile Systems:
Your medical history is very important because health care providers use that information as the foundation for medical decisions. Who has more interest in the accuracy of your information than you do?
You might say: writing the medical history is the doctor’s job. You are right. But, have you actually looked at the product of that work? — most people have not. Patients who read the doctor’s version of a medical history are astounded by the number of errors and the amount of missing information. To be fair, health care providers are goal oriented — as they hear the medical history they make diagnoses and once a diagnosis is made the details become less important.
Health care providers absolutely love a new patient that hands them a concise medical history. They love it because:
- They save time
- The information is more accurate and complete than usual
- They can take notes directly on the paper
- It is an aid to write their own version or enter data into a computer
The do-it-yourself (DIY) medical history is great for patients because:
- You don’t need to repeat it on forms, just write “see attached Medical History”
- You can print a copy when you see a new doctor or specialist
- You can take a copy to the emergency room
- You can keep it up to date with a wordprocessor
- You can store it on your computer or “in the cloud”
- Your health care visits can focus on current problems not old records
As helpful as this DIY medical record seems there are some important points:
- The record must be constructed the way health care providers expect — otherwise they will not read it or use it.
- The record must be concise — try to get it on one page (not more than 2 pages)
- You must not omit diagnoses or include any self-made diagnosis
- Avoid duplication — if you include something in one section do not put the same information in another section.
- This is not a test. You can “cheat” by copying from the medical history created by one of your health care providers. After all, it’s your medical history. Make sure you get copies of any “History and Physical” done by your providers.
When you see a new health care provider you should take 2 things:
- A copy of your DIY medical history.
- A small piece of paper with the 3 concerns you want to talk to the provider about
Now, to the nuts and bolts of the DIY medical history. Here are the categories:
- Identifying information: Name, Date of Birth, Address, Phone number
- Past Medical History:
- various diagnoses with dates of any hospitalizations and causes
- recent blood tests, x-rays or other tests with results (or attach report)
- Past Surgical History: name of surgeries with date, surgeon, and hospital
- Childhood illnesses: birth defects or serious illnesses when a child
- Obstetrical History (women): pregnancies and outcome, number of children
- Psychiatric History: depression problems etc. and list of hospitalizations
- Family Medical History: just parents, siblings and children
- Social History:
- where you live, with whom, occupation, when retired etc.
- habits including smoking and alcohol consumption
- advance directives (living will, 5 wishes etc.)
- drug names, strength, how often taken, for what
- pharmacies with phone and fax numbers
- Drug Allergies
- Drug Intolerances or side-effects, what drug and when it happened
- Food or Inhalant allergies
- Immunizations: which vaccines and when
- List of current health care providers: primary care, pediatrician, ob/gyn, and specialists
- Prefered hospital in case hospitalization needed
- Emergency contacts: names, relationship and phone numbers
Everybody complains about doctors or other health care providers. But, according to a survey by Consumer Reports last year 75% of 49,000 people surveyed were very satisfied with their doctors. If you search the Internet that view is not obvious (go ahead, try a search).
So, it should be easy to see what people like about health care providers since so many people like what they do (or at least some things they do).
Leave a comment about a very specific thing your health care provider, or surgeon, or specialist, or hospital or clinic really does well.
Ok, just a few rules:
don’t include names, don’t include things like personality or appearance or grooming
do include things that seem efficient, things that seem professional, a process that solved a problem quickly, comments that made you feel better, or anything that made you say WOW.
The intent is to let other people know what really good care looks like.
I will start the ball rolling — the first comments are mine.
Today, 7/12/13, the Wall Street Journal has a front page story “Hospitals Prescribe Big Data to Track Doctors at Work” by Anna Wilde Mathews. The past 20 years have seen numerous efforts to give performance data to doctors with the hope the doctors will change practice patterns. Each time the efforts have failed. The Wall Street Journal article paints a hopeful picture that faster and more accurate data analysis will finally solve health care quality problems.
Insanity: doing the same thing over and over again and expecting different results. Albert Einstein
Clearly, collecting such data does reveal quality problems. In fact, the first step to correcting quality problems is finding them.
But, there are three fatal flaws in thinking that telling doctors about their own quality problems will really help patients:
- Studies of errors happening with complex tasks show the best human performance is an error rate of 1 – 10 errors per 100 tasks. Meaning, no matter how much you flog doctors with data there is a human limit to performance. Patients want performance in the range of 1 error per million which requires computers and systems.
- By looking at errors as a personal failing instead of a system failure innovation is inhibited. People tend to say “try harder” rather than “try something new”.
- A data driven focus on past problems actually blurs the view of new solutions and new treatments. Decision support can assist physicians to adopt new methods and treatments. Currently it takes about 15 years for proven treatments to enter routine practice — big data does not move that forward.
The electronic medical record (EMR) solves many of the problems (this is not big data but something called decision support). The big data approach is to tell doctors they failed and to try harder in the future. Instead, decision support shows doctors choices at the point of making a decision. For example, as the physician is using the EMR with a patient in the room these messages could show up:
Mammograms: the EMR tells the physician that mammograms will be ordered every year unless you check here [ ].
Tetanus vaccination: your patient has not had a tetanus vaccination. Give the vaccination now? [ ]yes [ ] no
Asthma medications: Refill data suggests the patient is not taking enough controller medication. What is the reason? ___________________.
Chlamydia screening: Your patient (age 16-24) has not had screening. Do it today? [ ]yes [ ] no
Bronchitis treatment: Treatment guidelines for acute bronchitis do not include antibiotics. Is the diagnosis correct?. Consider other agents like cough suppressants or bronchodilators.
Diabetes & blood sugar. Guidelines suggest checking A1C hemoglobin every 3 months for diabetics taking insulin. Order A1C now? [ ]yes [ ]no
Conclusion: It is important to collect data on individual doctors and on hospital systems. That data can tell whether quality improvement efforts are working. But, doctors need computer driven decision support at the time of ordering treatment or tests, not criticism days or months later. Patients benefit immediately from decision support but only later, if at all, from big data.
The per capita annual drug cost in the US is about $900 and in the UK about $200. How can this be? Drug companies are multinational so we all purchase from the same sources.
There are 2 types of drugs in all countries:
- Generic drugs: no basic research cost, multiple manufacturers and generally low cost. 80% utilization but only accounts for about 20% of national drug costs.
- Brand name drugs: still protected by patent, price includes significant research cost, one manufacturer and generally high cost. 20% utilization but accounts for about 80% of national drug costs.
The formulary: this is the list of drugs provided by a pharmacy or hospital. Although there are thousands of drugs manufactured only a small group are included in a given formulary. A formulary usually includes the least expensive drugs and avoids drugs with duplicate actions. Brand name drugs cause problems since they may be a one of a kind without alternatives.
Prescriber intent: prescribers anywhere usually try to minimize drug costs for the patient by prescribing the lowest cost drugs that treat the medical problem adequately. Unfortunately, US doctors often don’t know which drug is most cost effective and succumb to the advertising of manufacturers.
How it works in the US:
Hospitals must include drugs in the price of hospitalization so hospitals have a restricted formulary constructed to minimize cost. Outpatients are different, insurance companies that pay for drugs usually expect the patient to pay a percentage of the price: 1) generic drugs — small copay 2) moderate price drugs — medium copay 3) expensive drugs — high copay (or no coverage at all).
How it works in the UK:
The NHS sets the price it will pay pharmacies for generic drugs and purchases generics in bulk for hospitals. The UK has forced a “voluntary” agreement on brand name drug manufactures that limits the profit they may make — sometimes called a “cost-plus” arrangement. Pharmacies and hospitals obtain brand name drugs under this national agreement. The National Institute of Health and Care Excellence (NICE) investigates the cost-effectiveness of drugs and provides that information to prescribers.
Conclusion: Most advanced countries like the UK limit drug company profits or simply set prices for drugs. People in other countries enjoy lower drug costs than in the US. Multinational drug companies make large profits in the US because of the lack of a national strategy. And, the US supports the research of many drugs with grants to Universities from taxpayers. The drug companies which are restricted in other countries extract a high profit from US patients and benefit from government research.
Solution: Restrict drug company profits in the US similar to other countries. Mandate the FDA to provide cost-effectiveness data on drugs and devices. Develop a national formulary for Medicare and all other government programs.
Bill(*) had a really bad headache and died before he could call 911. He died of a complication of warfarin which he was taking to prevent blood clots. Instead, the best intentions to prevent a stroke lead to uncontrolled bleeding in the brain, high pressure inside the skull and death.
Warfarin and other anticoagulants are necessary medications but also dangerous medications. People take the medications because the risk of blood clots, for them, is higher than the risk of anticoagulation. The last thing a patient wants is for drug management errors to tip balance so the risk of the medication is too high.
So, what are the expectations of people who take warfarin? What do they expect of their providers? What do the providers expect of them?
- Patients expect providers to follow drug guidelines to the letter
- Providers expect patients to follow instructions and learn about warfarin
- Patients want to be in the loop — meaning the risks are high so they want to be in a position to make sure the necessary communication happens and dose adjustments make sense.
- Providers need to be able to contact patients and expect positive feedback — “message received, will change dose to ___ as directed”
- Patients expect a consistent process no matter the day of the week or which provider is on call.
- Above all, patients expect adequate prevention and minimum risk.
Here are several marks of quality warfarin management:
- The same day of drawing lab (INR) the patient is informed 1) the result 2) the change in dose and 3) the date of the next lab. Finger-stick methods with quick results allow some offices to provide instructions before the patient leaves the office.
- The patient is asked to keep a record of results and instructions. And, to “read back” the instructions. Thus the provider knows the patient got the right message.
- The patients have the phone number to call for any evidence of abnormal bruising or bleeding. They should expect to get lab tested or go to the emergency room.
- There is no impediment to getting the warfarin prescription refilled when needed.
- Providers use computer applications or paper tables to select the correct warfarin dose. Only if there are unusual problems do they deviate from established guidelines.
- If the INR is out of range the dose is changed and the INR is rechecked within a week — even if the patient was on a monthly lab routine.
- The day the INR is checked patients do not take the usual warfarin dose until the results are available.
- Providers never say “just keep taking the same dose unless we call you”. That is a recipe for disaster if a lab test is lost or sent to the wrong provider.
- The lab the patient uses is open 7 days a week.
- Providers instruct patients to follow a consistent diet so the amount of vitamin K in the diet is fairly constant. A sudden drop in vitamin K intake causes the INR to rise and bleeding risk to increase.
Back to the case of Bill. He forgot to get his INR checked on Friday and nobody called him to check why. He knew the lab was not open on the weekend. The nosebleed was unusual but not too bothersome — besides, his doctor was not on call and he did not know who to call. He took a slight fall and bumped his head – he didn’t think small head injuries were risky. He had a good memory but sometimes forgot how many warfarin pills to take on Saturday so he took 2. Wrong, wrong and wrong. The outcome might be better if the medical process was better and if patient education was better.
(*) Bill’s case is not real but such deaths have been reported. It is true warfarin is related to rat poison.
According to Louise Radnofsky of the Wall Street Journal 7/1/13 “Insurance Costs Set for a Jolt“. Should this really come as a surprise?
No surprise indeed, because very little has been done to reduce health care costs. The ACA has 2 important financial provisions:
- Everyone must purchase insurance
- Insurance companies can’t cherry pick healthy people and dump the rest on public institutions.
The rise in total cost of US health care will continue but those who pay for it will change. The bizarre system the US now has which forces hospitals to care for the uninsured by cost-shifting to private insurance will stop. The cessation of cost-shifting will make costs more transparent but not smaller.
The problem is in the transition from one method of finance to another. As the transition proceeds hospitals get a windfall profit, insurance companies raise rates due to uncertainty but score a profit with so many new policies, premiums rise for many, and taxes go up for some. Eventually, the system finds a new equilibrium.
Sadly, Congress has been paralyzed by partisan issues so no improvements to the ACA have been made and no actions taken to make health care more efficient. Other countries with health systems seem to steer the ship of healthcare but the US can’t seem to disengage the autopilot.
It seems likely that each State and even some large cities will need to act without help from the federal government. We need ACOs to reduce cost and States could help that system grow.
That’s my view, what’s yours?