Monthly Archives: January 2014

The Consequences of “Over-Testing”: Doc, Am I Glowing in the Dark?

In medicine today diagnostic testing and advanced imaging is readily available and widely utilized in most every clinical setting  Many physicians have given up the stethoscope and physical exam in favor of an echocardiogram and a CT scan.  Fear of “missing something” pervades every Emergency Department and has resulted in hundreds of thousands of unnecessary testing costing billions of dollars in healthcare expenditures.  Of course, the driving causes of increased testing and utilization of advanced imaging are numerous and complex.  Unfortunately, in my experience, the two most common reasons are fear of malpractice litigation and a desire for greater reimbursement.

How do we best determine when to test?

The most basic testing techniques rely on Bayesian statistics–the question to be answered must be well defined and then a clinician must determine a pre-test probability of the presence (or absence) of the disease in question.  The best utilization of a diagnostic test is when a clinician has an intermediate pre-test probability that a particular disease state is present.  If the pre-test probability is low, then there is no need to test.  If the pre-test probability is high, then the clinician should proceed with treatment rather than an additional testing step.  In the case of coronary artery disease, if you have a patient with multiple risk factors and symptoms that are a bit atypical, diagnostic testing with a stress test with imaging makes sense.  If you have a young person with no risk factors, and very atypical symptoms diagnostic testing does NOT.  In contrast, if you have a patient with classic angina, an abnormal EKG and multiple risk factors you may want to forgo diagnostic imaging and proceed directly to cardiac catheterization.

What are the risks associated with radiation?

In today’s New York Times, authors Redberg and Smith-Bindman argue that the over utilization of CT scans and other radiation based diagnostic testing results in a significant increased risk for certain types of cancers.  I tend to agree.  The radiation exposure associated with one CT scan is equivalent to more than 500 plain chest X-rays.  The FDA estimates that a patient’s lifetime risk of developing cancer from radiation exposure to a CT scan approaches 1 in 2000.  To place this all in perspective, the survivors of the atomic blasts in Japan were exposed to the equivalent radiation to two CT scans!  In addition to CT scans, nuclear medicine based stress testing in cardiology also exposes patients to large doses of radiation (even more than CT).  These tests are recommended at particular intervals by the American College of Cardiology in patients with known coronary artery disease (CAD) or in cases with suspected CAD with appropriate risk factors and baseline characteristics.  However, just as with CT scans, these imaging tests are often over-prescribed and overused.

What are the root causes for the over-use of diagnostic testing?

Much of the over testing seen in the US is due to fear of litigation.  Doctors, as a whole, want to do their very best for patients.  When the encounter a patient with a complaint that seems routine, many astute clinicians also think about more serious diagnoses when formulating a differential.  Anecdotes from colleagues where a particular serious diagnosis was “missed” can often lead to unnecessary testing.  Moreover, the trial lawyers and “ambulance chasers” are an ever present thought for many clinicians.  The fear of being sued for missing a lung tumor in an asymptomatic patient can also lead to more unnecessary and non indicated testing.  This phenomenon is yet another important reason that we must persue tort reform in the US today. Unfortunately, another reason for overuse of CT scanning and other types of imaging is profit.  Profit and finances have no place in the clinical evaluation of a patient–however, economic realities have blurred these lines considerably in the last decade.  There are some clinicians that put reimbursement ahead of patient welfare.  Abuses such as routine, non indicated imaging for cardiac patients has been declining.  New guidelines and more government and regulatory scrutiny into these types of exams seems to be having a positive effect on reducing unnecessary radiation exposures.

What can we do to advocate for ourselves and our patients?

As a patient, it is essential that you ask your clinician precisely why the test is being ordered and exactly what impact the result will have on your clinical management.  As physicians we must have very clear reasons (and well documented reasons) for ordering tests.  Tests should remain an adjunct to history and physical exam for the diagnosis of disease–not a replacement for clinical experience and expertise.

So, next time you order a test (or your doctor orders a test for you) make sure you take time to understand how the exam is going to impact your course of treatment–if you are at a fork in the road, the best test should determine whether you take the road to the right or the left…..If you and your doctor already know which way to go, the test may only be another chance to “glow in the dark…”

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Managing Risk and Modifying Lifestyle: The Role of Mobile Applications (Can an App a Day Keep the Doctor Away?)

Applications for mobile devices are commonplace.  These small but often sophisticated programs are quite varied and allow for anything from vehicle GPS navigation (Google Maps), taxicab or car pickups in New York City (Uber)  or rating wines and restaurants (Zagat).  As with most new gadgets and technologies, medicine and healthcare provide many opportunities for expansion and use. When we examine the available applications found at the Apple App Store, it is evident that medical mobile applications continue to be developed at a remarkable pace.  In response, the FDA is actively involved in developing strategies for evaluation and approval of new medical related applications as the market continues to rapidly grow and evolve. (And that in itself is a whole separate issue blog about!)

As the medical application industry grows, more disease specific programs have been created.  There are already several advanced apps that allow for tracking medications, daily weights, blood pressure and blood sugars–However, some of the more popular applications focus on more basic strategies for improving overall health status.  Many of these newly developed general health and fitness applications focus on self help, diet and exercise.  As we all know, diet and exercise are key components to making wholesale lifestyle changes and these changes can significantly reduce risk for chronic disease.  It stands to reason that many of the new medically relevant applications have focused on tracking dietary habits–calorie counts, food dairies, etc.  In particular, dietary applications can make a huge difference in our behaviors.  For instance, an application that tracks everything you eat can be quite eye opening.  In general, we have no idea as to the calories we take in on a daily basis–combine this with an app that can also track calorie expenditure and you have real time data that can be the impetus for change.  Data empowers us all–both doctor and patient.

This week in the New York Times, personal tech author Kit Eaton explores several new applications for iOS and Android that are specifically devoted to diet.  These applications provide the user the ability to create a food log and to actually scan labels to obtain exact nutrition information and calorie counts.  These applications then can track your exercise habits and estimate your calorie expenditures–some are even able to make suggestions for healthy food choices based on your pattern of intake and output.  Most start with the input of basic data such as height, weight and age.  Particularly in our current era of cost containment and as we stand in the shadow of the albatross that is Affordable Care Act, we must spend more time on prevention.  Preventative care is the single most important thing physicians can do for their patients during this time of reform.  We have long known that chronic conditions such as heart disease, type 2 diabetes and hypertension are directly related to obesity.  Obesity and obesity related illnesses account for nearly 150$ billion dollars of healthcare costs each year in the US alone.  Applications that provide assistance in lifestyle modification and risk factor reduction can have an enormous impact on our ability to successfully change negative habits. As we move forward as physicians, it will be important for us to engage patients and assist them in taking individual responsibility for their own health.  Applications are an important way for us to directly involve patients and promote change.

Based in California, an application known as Lift is working to make an impact now.  The motto on the Lift home page says it all:  “Unlock your potential..change your life”.  Working with researchers at UC Berkeley, Lift’s designers are now studying the effectiveness of individual diet plans on overall health and wellness.  Previous studies have compared the effectiveness of one or two diets against each other or a control–however, no one has ever evaluated several diets at one time via a mobile application.  The quantified diet project as it is known is likely to provide us with important information about the effectiveness of mobile technology and mobile “coaching” and its role in patient compliance and success.  Moreover, it will provide the opportunity to directly compare several popular diet plans all in one large study group.

Mobile applications have the potential to revolutionize preventative care.  As we continue to work to engage our patients and motivate them take individual responsibility for their health status, we must take advantage of emerging technologies.  Simple applications may result in significant changes.  Embrace change.  Embrace technology.  Advocate for your patients and prescribe an app today! (An APP a day make keep the doctor away!)

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Patient Engagement and Improving Outcomes: Tweeting for Success

Patient engagement is critical to success–particularly in treating chronic medical conditions such as heart disease, diabetes and asthma.  In this era of healthcare reform and cost-containment we must now, more than ever, rely on patient participation in their own care.  Studies have shown that when patients play an active role in the management of their disease, hospitalization rates and complications are minimized.  Examples of “engagement” include daily recording of blood pressure and heart rate, blood sugar logs, daily exercise logs, and the like.  Engagement requires that patients not only partner with their physicians during office visits but take individual responsibility for their own healthcare—showing up three times a year as a passive participant in the office visit is not nearly enough.

This week in the Wall Street Journal, author Laura Landro explores the issues surrounding patient participation in management of chronic illnesses.  In her piece, Ms Landro uses chronic kidney disease as an example of how patient engagement and strict adherence to a physician’s recommendations can make a difference in outcomes.  Exercise, dietary changes and monitoring of blood pressure can make a significant impact on kidney disease and, in many cases, slow progressing to kidney failure for many years.  However, this type of intervention only works when the patient and physician are “partnered”.  With increasing workloads and more clerical demands, physicians are not able to reach out to patients as often as they would like between formal visits.  Through patient engagement, however, we have the potential to bridge the gap between visits.  As Ms Landro points out, one of the biggest challenges is in “getting the word out” to patients.  Most patients lack disease specific education and are not sure how to go about “at home” management.  Moreover, with increasing patient volumes and less time available to spend with each patient in the office, many physicians are not able to adequately educate patients during a quarterly office visit.

What is the solution?  How can we educate more patients effectively?

For me, the answer is simple.  Let’s use the tools we have that are easily accessible to most patients. Today, more than 60% of all Americans own a smartphone or other “connected” mobile device.  Most households have at least one computer.  While today’s children are “born” understanding and interacting with the computer and mobile world, older Americans are also becoming more tech savvy.  Social media and the virtual world lend itself perfectly to helping support patients as they engage in the co-management of their own diseases.  Virtual health coaching and support can be the way in which we support patients between “real time” office visits in the future.   Applications for smart phones such as Lift can be an essential part of engagement and ultimately may become part of routine patient care activities.

1. Twitter:  Twitter can be a great way to conduct “disease-specific” chats–engage patients virtually with regularly scheduled group events identified by a specific hashtag.  A physician or other healthcare provider can serve as a moderator for the chat.  This is a great forum for support groups, educational events and information exchange.  As a legal side note, this is NOT an acceptable forum to provide specific medical advice or patient care.  It is more about support, engagement and education.  For patients it is a wonderful way to “check in” and track their progress in a supportive non threatening environment.  For instance, a twitter chat amongst patients with kidney disease may involve an exchange of healthy recipes.  By connecting with others (and likely a healthcare professional who is moderating the chat) the patient is supported and remains engaged during the time between real live office visits.

2. Blogging:  Regular blogging can provide a wonderful resource for patients and their families.  Disease specific blogs may provide nutritional advice, exercise tips, and help disseminate important information about drugs and disease.  Blogging can help educate and inform patients–as Ms Landro correctly points out in the WSJ education is a major reason that patients sometimes fail to engage.  Thru regular posts (by physicians, nutritionists, exercise physiologists, etc) a broad range of topics can be covered and the patient is provided with the tools they will need to succeed.

3. Facebook posts:  Maintaining a “Disease-Specific” Facebook page for patients is another outlet for successfully educating patients and disseminating information between office visits.  These pages can be a great place to post pictures of interesting recipes or provide information on new therapies for a particular disease.  As with Twitter, clinicians must take care to provide information only and NOT use it as a platform for discussing privileged medical information or for providing treatment.

4. Prescribing Apps:  As I have discussed before in previous blogs, applications for mobile devices are likely to play a major role in disease management in the future.  There are already numerous applications available for tracking blood pressure or blood sugars.  These applications are a wonderful way to store data and share the data with physicians during a live quarterly visit to the clinic.  The physician is better able to track progress and the engaged patient is able to see real change.  In fact, Lift has developed an app that is specifically designed to help patients achieve health related goals and is in the midst of a large diet tracking and comparison project called the quantified diet.

Patient engagement is critical to the management of chronic diseases under our new healthcare system.  Physicians have less time to devote to patient care due to paperwork, documentation mandates and higher volumes.  In order to maintain a high level of care and clinical success, we must also rely on patients to take individual responsibility for their own healthcare issues.  In the past, engagement between visits has been difficult to accomplish due to the lack of resources available for communication and interaction with patients.  Now, with the proliferation of mobile technologies and the use of social media outlets patients can be engaged daily–if they will accept the responsibility of co-managing their own disease in concert with their physician.  With widespread engagement, I expect to see outcomes improve and patient lives changed for the better.  #Engage now!  (in 140 characters or less!)

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The Electronic Medical Record Mandate and Managing Fraud: More Government Ineptness?

The Obama administration has clearly mandated that Electronic Medical Records (EMR) will be necessary in order to comply with Federal regulations for reimbursement for both hospitals and physicians.  The transition to EMR is an important step towards streamlining patient care–however, the current implementation of EMR is fraught with complications, workflow issues and system wide “bugs”.  At this point in the US there are numerous EMR systems and no absolute standard which continues to make communication between different hospital systems and physicians difficult at times.  I realize that the EMR mandate has spanned more than one administration and let me state at the very outset that I am 100% FOR the implementation of an electronic medical record system–However, I would like to see the transition be done in a stepwise, intelligent way that allows for universal portability within the US.   Moreover, the EMR should be electronically available to all patients via smartphone and tablet download from the mysterious (and hopefully secure) “cloud”.

The EMR when properly managed can provide detailed notes that are easily applied to templates for billing medicare and medicaid documentation (it allows MDs to correctly bill the level of service based on comparison of the patient’s newly created chart note to standards for required components).  However, the time involved in documenting via EMR (especially in the transition phase in a busy practice) can be overwhelming.  Physicians and other providers are already overwhelmed with offices full of patients–longer hours, more appointments and loads of new paperwork. The Affordable Care Act (ACA) promises to add loads of newly insured sick patients to the practice workload.  Add to that a cumbersome computer system and it is likely that errors will occur.

This week in the New York Times, Abelson and Creswell report on the new Department of Justice focus on EMR fraud activities.  The Office of Inspector General (OIG) for HHS released a report on Tuesday (the second in two months) warning of the potential widespread fraud and abuse occurring as a result of EMR implementation.  The warning specifically cites a lack of oversight and safeguards in the Federal government to prevent these from occurring.  The government has already spent nearly $22 Billion dollars on the push for conversion from paper to EMR in the US.  (sound familiar?  rapid roll out of new technology without proper evaluation).

According to the New York Times report, the central issue with the EMR and potential fraud has to do with the lack of regulations surrounding the common practice of “copy and paste” known as “cloning”.  For many physicians, the ability to cut and paste data and information from one place to another in a note or within a patient’s particular chart can significantly improve efficiency and reduce the amount of time that is spent inputting redundant data into a patient’s record.  Critics of this practice, including the OIG, suggest that in many cases the importation of data from note to note or chart to chart results in “overbilling” for services that were not in fact rendered.  For example, if a chart note from a follow-up visit of moderate complexity  is “cloned” with data from a previous visit where the level of service was more extensive than the current visit, then charges may be filed for an level of complexity that was not, in fact, provided.  The OIG statement goes on to warn that their “level of involvement in EMR cases [will] increase” and that dealing with documentation “fraud” via cloning in EMR will become a “top priority”.  In a survey conducted by HHS and released in a previous report, the OIG found that very few hospitals and medical practices have any guidelines or restrictions on “cloning” notes for documentation.

Once again, in my opinion, our government has missed its mark.  Instead of carefully creating a universally acceptable and streamlined EMR that allows for responsible and efficient data entry AND migration of data to subsequent encounters, federal regulators have issued yet another mandate without a clear vision of its implications.  As I stated earlier, I believe EMR is vital for patient information management and will ultimately help us provide more streamlined care that is evidenced based.  Unfortunately, the current EMR systems that are in place do not place a priority on ease of use, efficiency or portability.  Although I am sure that there is some intentional documentation fraud occurring, I would suggest that the majority of physicians and other providers are simply trying to “get the job done” and move on to more important patient care activities.  EMR documentation can be slow and arduous.  During transition phases, many providers report 2-3 extra hours added to their days for documentation activities.  No physician wants to continually take a practice laptop home in order to finish entering EMR notes during family time night after night.  Cloning data is a simple way to carry over information such as medication lists, past medical histories and other information in order to improve efficiency while at the same time providing adequate documentation.  As with most things, this type of data migration is easy to abuse if physicians do not pay special attention to ensure that the migrated data is both accurate and representative of the work that was performed.

As the current administration has clearly demonstrated with the rollout of the  ACA,  as well as with the new ICD-10 coding system and the EMR mandates, sweeping reform that is rushed to completion without a full understanding of its implications is doomed to fail.  Putting politics and power ahead of good sense has resulted in increased cost for these government mandated programs.  As a nation we must certainly work to prevent fraud and abuse as part of our efforts to curtail healthcare costs.  However, as we initiate reforms, we must do a much better job of anticipating issues with new technologies and work to deal with them on the front end–if we do not, we can expect costs to continue to rise.

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