Resilient Ambassadors of Change

Another delicious morsel of patient safety information!

Check out ten medical misconceptions on the Time website. 

CVS Minute Clinic Visit

Two nights ago, I was standing in my kitchen holding my cat, Shadow, pictured to the right.  A noise startled him and he decided to use my palm as a launching pad to catapult himself across the room to hide.

Unfortunately, as my hand is made of FLESH and his back claws are TALONS OF DEATH, I sustained a pretty nasty scratch, pictured below.  I wasn't sure exactly how "bad" the scratch was as far as animal scratches go... it wasn't as bad as if a bear had mauled me, but it was probably the worst cat scratch I've ever had, and as the happy owner of five cats, I've had quite a few.  I decided to just wash it out and slap a band aid over it.  However, when I woke up yesterday morning it wasn't any better.  It was actually stinging more than it was before, and was looking a little swollen.

Man, I don't feel like going to the doctor for this, I thought. Who has time to sit and wait for 50 minutes in the waiting room, and then another 30 in the office?  And that was even IF my doctor could see me today.  I realized that I haven't actually seen a live MD in the office for a long time.  I always see a nurse practitioner, which is just fine by me.  Anyone who can make me feel better is all right with me!  Then I remembered someone mentioning the minute clinic at CVS. 

The Minute Clinic is basically a one-person manned clinic IN CVS.  How much more convenient can you get?!  I found one close to me, as not all CVSs have them, and decided to take a ride over and see how long the wait was to see someone.

The door was closed, so I entered my info into the little touch screen waiting list and saw that I was at the top of the list.  Sweet!  I looked around at brochures and watched the little video provided in the area for what services are provided by the nurse practitioner, the costs for services, etc.  I was pleased to see so much information presented to the patient at once, and in different formats!

The actual visit was like something out of a training video.  The nurse practitioner introduced herself to me and shook my hand.  She asked me all kinds of questions about my cat (was it mine, was it up to date with shots, etc.), about what happened, how I've been treating it myself at home.  All of this before she even did any physical exam of anything!  She was gentle with the exam, and then asked if I minded if she turned her back to me while she typed up the notes.  She actually ASKED me if I minded!  While she was doing her notes, she started asking about medicine allergies, and accessed the CVS pharmacy database to see what other medicines I was on to check for interactions.  She sent the prescriptions right back to the CVS pharmacy (which, I should note, is a separate entity from the Minute Clinic) and asked me if I had any other questions.  Then she printed out all the discharge paperwork - including all the notes she typed up.  I almost laughed out loud thinking of that epsiode of Seinfeld where Elaine tries desperately to get a hold of her chart to see what her doctors are writing in their notes about her.

I don't remember ever feeling so satisfied with an interaction with a medical professional.  I received wonderful care from someone who actually seemed compassionate and interested.  And the icing on the cake?  When I got home and logged into my gmail account I already had emails waiting in my inbox to add the service into my google health account, along with a survey about my visit.  I'm sure you can guess how I rated it.  ;)

I would highly reccommend heading over to the Minute Clinic for anything that isn't too serious.  They accept some insurances, and have pretty good prices for folks who don't.  Check out their site for full details.  This patient was utterly impressed!

e-healthcare may cure many ills

Healthcare costs too much.  Patients are dissatisfied.  Physicians are dissatisfied.  Insurance companies have too much control--patients and doctors too little.  Medical records are scattered.  Too little information is available.  Too much information is available.  The physician workforce is shrinking.  So, what's the good news?  Internet savvy patients, doctors, and other innovative stakeholders are making strides in addressing some of these problems in ways that may become the basis for how healthcare is practiced in the future.

Many clinicians have overestimated the risks of online health resources to their patients and underestimated the benefits.   E-healthcare may be one of the most important cultural medical revolutions of this century, and the majority of physicians are not savvy enough to operate in this emerging culture.   Our future physicians will likely have the benefit of growing up immersed in the internet social and electronic culture, and hopefully with the skills to follow in the footsteps of the pioneers

The e-patient.  More and more, people are seeking healthcare online.  They research their medical problems on a variety of web-based medical sites (e.g., WebMD); they blog and use social networks to share with and learn from others with similar health conditions or interests.   Patients in force are abandoning traditional methods for obtaining medical advice and even treatment plans (i.e., physicians office) in favor of the more on-demand options that the internet offers.  The e-patient has a personal health record.  The e-patient requires a non-traditional approach to healthcare.  The e-patient is extremely active in their own medical care and requires a collaborative relationship with their physicians.  E-patients are blogging and using social networks to share with and learn from others who have similar conditions or interests, and have been for several years.  Our current base of healthcare professionals seem blissfully unaware of the impact that the e-patient might have on the skills they will need to best serve their patients in the near and far future.  The general population seems to be light years ahead in taking advantage of the benefits of the burgeoning social and collaborative electronic culture and tools than our medical professionals.  The net friendliness of clinicians and provider organizations is becoming an important new aspect of healthcare quality. 

The e-doctor.  Unfortunately, the e-doctor is a much more rare species that the e-patient, as the medical community is often slower to adopt changes that the general population readily embrace.  There are some pioneers and early adopters who are empowering and enabling their patients and themselves by embracing trends and adopting technologies to provide a higher quality of patient care and experience.   In addition to encouraging the e-patient as a collaborator and an informed partner in their own healthcare, the e-doctor is a pioneer, often abandoning traditional structures that act as barriers (e.g., insurance reimbursements, traditional office visits, overhead, etc.).  In his practice, the e-doctor is in direct contact with patients, taking advantage of text messaging, email, and social media in order to facilitate treatment and education of their patients.  The e-doctor utilizes cost effective options when running his practice and provides cost effective choices for patients.

Hey I think I've spotted one!  Have a look and listen to Jay Parkinson of Hello Health describe his innovative approach to healthcare. 

Jay Parkinson, Hello Health from Health 2.0 on Vimeo.

A Veritable Treasure Trove of Links

If you're trying to find a good doctor, or are just interested in looking at how certain places do this kind of thing, check out this article.  Page two lists about a billion¹ links that are informative as all heck.  It warms the cockles of my heart to see so much patient-centered information gathered in one spot.

¹ may be a slight exaggeration

Pay for performance (P4P)--How's my driving?

The first time I heard about P4P, I thought what a great old idea!  Didn't they call it "piecework" back in the day?  Why shouldn't I be paid more if I could churn out 60 widgets in an hour compared to the guy next to me making only 43?  Well for one, maybe his widgets were better than mine.  Maybe I was working with inferior widget parts.  Maybe someone on the widget part line slowed him down.  There may be reasons why we are no longer paid by the "piece." 

Surely churning out patients was not what health insurance companies had in mind, so P4P must be tied to patient outcomes or satisfaction or some other measure that the physician is performing at his best.  So what's the fuss?  As a patient, I certainly would like to know that my physician is a top performer.  Why wouldn't they want data about their patient outcomes and satisfaction collected, analyzed and shared with insurance companies and patients?  Maybe their patients are sicker, poorer, and unable to afford to comply or follow up.  Maybe they have no control over the interactions between staff and patients. Maybe they are powerless to fix system problems within a hospital. There may be reasons why physicians are leery of embracing P4P sponsored by insurance companies. 

Today, buried in an otherwise engaging post on The Medical Quack, I found a reference to a kind of P4P that could affect me more directly in the not so distant future. On it's face,like piecework and physician P4P it seemslike a great idea. I drive carefully and I pay less money for car insurance. I have a spotless driving record--no accidents or tickets (except the parking tickets my sons get when they borrow my car).  I should be paying less for car insurance. It seems Progressive Insurance has a device that tracks your driving habits, coupled with a program called My Rate promising lower rates. You can even log on to the website and track your projected renewal rate based on your driving. What if my rates go up? What if I can't get insurance anywhere?  Maybe the device was faulty. Maybe I lent my car to my son (the one who gets the parking tickets).  Maybe I was driving erratically while dodging the other nuts on the road. Maybe there are reasons to suspect the motives of insurance companies.

I'm not sure money is the best motive for improving your widget making, driving, or patient care. I'm pretty sure insurance companies and other third parties that stand to gain while we lose are NOT the best choice to drive improvement. 

Is increased regulation in the Internet's future?

I was tempted to answer the question posed in the subject line with a simple, definitive "yes", but I realized I should probably elaborate a bit - after all, "yes" isn't much of a blog post. 

  The concept of identity has been intimately linked to the Internet since its beginnings - after all, computers have identities, users have identities, and all have to be managed as part of the Web.  We choose usernames and passwords and use them to manage our online identities; but a lack of a pervasive standardized identity management system like Microsoft's .net software (a la Identity 2.0) enables users to hide behind a layer of anonymity.  MrKewlD00D22 isn't afraid to speak his mind on the discussion board of his favorite science magazine, even if he is painfully shy in person.  PunkRockGrrl87 and MackDaddy00 chat online each day, but their real-life counterparts have never met.

However, as the lines between reality and virtual reality become more blurry, it seems identity is more of a sticky situation. Take for example the recent, very unfortunate story of a mother pretending to be a teenage boy on Myspace for the sole purpose of harassing one of her daughter's female classmates, which ultimately ended in the 13-year-old girl's suicide.  The mother had been facing up to 20 years in prison for conspiracy charges, but the conspiracy charges were thrown out and she now faces 1 year in jail and $300,000 fines for 3 misdemeanors.  This situation brings to light all sorts of regulatory issues around the Internet. For example, if one is to be held personally accountable to the Terms of Service on a site, then somehow their online identity must contain meaning that links to their real life.  And how many "teeth" do the Terms of Service have in terms of the law?  Do the same rules apply online as they do in real life? 

These are important questions, and are becoming even more important as future generations engage with and build upon the giant information monstrodome that is the Internet.  Frankly, I think the time for more regulation with regard to identity (and information veracity) is far past its due date.

The doctor will see you now

Poking around in one of our latest areas of interest, Clinical Decision Support Systems, I found my way to FreeMD, subtitled your interactive medical library.  Dr. Stephen Schueler, the virtual doctor, interviewed me about my "problem" and provided me with a triage report containing:

• conditions of most concern that may be causing my symptoms
• recommended time frame to see a doctor
• a list of tests that might be done
• where I should go for care (ER vs office)
• links to home care information
• links to information for worsening symptoms
• a summary of the report including history, positive and negative findings

For the particular problem I presented with, Dr. Schueler was completely accurate and gave good advice.  However, the symptoms were very straightforward.  I tried it with more vague symptoms, so I had to answer a lot more questions and there were more "conditions of concern" to be explored.

The site was easy to use and overall I thought it a cut above other sites where you can go with symptoms in search of a disease.  A far cry from replacing the real thing though. Try it out and judge for yourself.

According to the About section on the site, FreeMD is written and maintained by physicians at DSHI Systems, a company in business since 1989 developing symptom-based decision support systems.

So what is a medical home anyway?

Given numerous recent news headlines, blog posts, and Google alerts, the concept of the medical home is gaining momentum and you may be in the minority if you admit to not knowing what the fuss is all about.  I knew it was probably something I should pay attention to, but I just could not drum up much interest in reliving those months when mom-mom's living room was transformed into a makeshift hospital ward complete with the bed that cranked up and down, a portable potty, food tray, bedpans, and the nurses and aids who were "helping" mom-mom die. Why would anyone want a medical home? 

I wasn't even close!  I should have followed my instincts and boned up on my medical home knowledge so that I wasn't just shaking my head up and down when the phrase came up in a recent advisory committee meeting.  So, for those of you who were nodding right along with me, here's the scoop.

According to the Patient-Centered Primary Care Collaborative,

The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care to adults, youth and children.  The PCMH will broaden access to primary care, while enhancing care coordination. Primary care physicians practicing in the highest level medical home will:

• Take personal responsibility and accountability for the ongoing care of patients;
• Be accessible to their patients on short notice, for expanded hours, and open scheduling;
• Be able to conduct consultations through email and telephone;
• Utilize the latest health information technology and evidence-based medical approaches, as well as maintain updated electronic personal health records

...and much much more.  Click here to read the PCPCC Brochure 

The Patient Centered Primary Care Collaborative was created to change a health care system that does not work for anyone--patients, providers, and those purchasing health care.  Its members include representation from employers, primary care physician associations, health benefits companies, trade and professional groups, and health care quality improvement associations. 

I've also read that pediatricians are credited with developing this concept and that the American Academy of Pediatrics, the Americal College of Physicians, the American Academy of Family Physicians, and the American Osteopathic Association teamed up to develop the medical home principles.

Now that we're up to date on the what and the who, I'll keep a lookout for any buzz on this trend toward a more cost effective and efficient, patient-centered model of health care.

Finding Doctor Right

In a special section Decoding your health, the New York Times provides some solid information and advice to consumers in a variety of articles around topics like Googling your health, popular medical websites, FDA approval for medications, alternative medicine, and more. 

One of the articles, You can find Dr. Right, with some effort, gives consumers some direction for selecting a physician, using what little objective data is currenty available, as most consumers continue to rely largely on word-of-mouth referrals from family and friends.

The article suggests contacting the usual suspects like your State Medical Board for licensing information, your health plan (as some are beginning to provide some quality measures) and the American Board of Medical Specialties for specialty certification information, as well as some of the emerging services offering physician ratings.  Still, this is precious little information as the basis for a most intimate doctor/patient relationship--no quality measures of physician performance or even descriptive data about physicians' practices.

No surprises here, good objective data is hard to get, and volumes of subjective physician rating data will likely not provide the basis for good decision making.  The relevance and timliness of our discussions around physician matching, performance measures of physians in practice, physician practice profiles, and data compilation and report out continues to be supported by the increasing public demand for quality measures for physicians.

"...patients cannot get their hands on a wealth of information about physicians that is compiled by government agencies....  The Medicare program recently started a physician quality reporting iniative,...information is not yet public."

In an attempt to obtain data about procedures done by physicians (e.g., knee replacements, prostate surgery, etc.), last year the nonprofit group Consumers' Checkbook won a lawsuit granting access to Medicare's physician records.  The government is appealing the decision--there goes that big, publicly-available data set that we've been dreaming about.

Physician communication skills -- predicting and preventing future woes

Many thanks to a local scouter in our tech services unit who passed along an article from Science Daily that he thought would interest us.  The article Physician's 'dashboard' takes a measure of communication skills reports on a study that utilizes a new system to instantaneousy report patients' perceptions of recent encounters. 

The system, developed by researchers at the Medical College of Georgia School of Medicine, uses a touch screen kiosk where patients respond to six communication-related questions immediately following their encounter with the physician.  The other part of the system is a 12-inch screen that displays near real-time results of ongoing patient surveys in a colorful, easily interpretable visual display.  Additionally, the system provides private feedback to individual physicians in the form of a weekly email.  The purposes of the study are to 1. determine whether or not patients will complete the survey immediately following their visit, and 2. how physicians will respond when they actually have data.

The article quotes Dr. Pamela Wagner, who teaches communication skills to first year medical students, as saying, "The number one predictor of malpractice is poor communication, not that something bad has happened." Dr. Wagner goes on to say, "The innate desire to do well may help physicians modify their habits when they see vivid evidence that they are not."

While reading this first article, another one caught my eye.  Doctors' 'bedside manner' test predicts patient complaints reports on the results of  McGill University study of 3000+ practicing physicians who took the MCC clinical skills examination and the relationship between low scorers and the likelihood of patient complaints.

"Low scores on the exam were quite predictive," said  RobinTamblyn, scientific director of McGill University's Clinical and Health Informatics research unit. "It was really like a dose-response relationship. The higher your score, the less likely you would get complaints.

Both of these articles indicate the importance of good physician communication skills in optimizing patient care and satisfaction and/or preventing malpractice.  I sure hope the MCG is successful in providing practicing physians with data that will enable them to recognize a need for improved communication skills.  As for all of those low scorers on the clinical skills exam--maybe the bar should be set higher...