Family Medicine Notes
Docnotes - Occasional Notes from a family physician - since 1999
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While details are thin, hereâs a first pass at comparing and contrasting Google Health (GH) and Microsoft HealthVault (HV). Overall, ...
Sat, 08 Mar 2008 20:17:09 -0500 -
- Google Health
This is a must-see :-)
Mon, 03 Mar 2008 19:20:12 -0500 - Mike Arrington's 23andMe DNA Results
Mike Arrington posted his 23andMe DNA Results - and I'm (finally) convinced that genetics are on the brink of becoming relevant to primary care medicine. Within a half-decade, these tests will be generally available, and within a decade, it wouldn't surprise me if insurance companies considered such testing appropriate and reimbursable. THe key challenge will be for the EMR vendors to incorporate these results into action-able rules that help support evidence-based care. There will be no other way for us to use these tests - as there is no way that any human will be able to remember all of the possible genetic variations - or their clinical implications. Many ethical considerations to follow, of course.Tags: Genetics
Sun, 02 Mar 2008 23:49:40 -0500 - Developing mobile VoIP: or why I hate all the mobile industry
Ruslan Zalata, a Thoughtful Siberian, writesDeveloping mobile VoIP: or why I hate all the mobile industry
It's an interesting essay on his attempts to create a remarkably useful tool. I've used his gtalk2VOIP for about a year - and I love it. I'd much rather do business with a struggling optimistic Siberian than some faceless BigCo. Check out gtalk2VOIP.
Wed, 06 Feb 2008 11:42:51 -0500 - Trends in Acute Otitis Media-Related Health Care Utilization -- Pediatrics
This study suggests that that things are getting better!Trends in Acute Otitis Media-Related Health Care Utilization by Privately Insured Young Children in the United States, 1997â2004Fangjun Zhou, PhDa, Abigail Shefer, MDa, Yuan Kong, MSb and J. Pekka Nuorti, MD, DScaa National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgiab Science Applications International, San Diego, California OBJECTIVE. The goal was to estimate the population effect of 7-valent pneumococcal conjugate vaccine on rates of acute otitis media-related ambulatory visits and antibiotic prescriptions for <2-year-old children enrolled in private insurance plans.METHODS. We performed a retrospective analysis of a defined population by using the 1997â2004 MarketScan databases, which included an average of >500000 person-years of observations for children <2 years of age. Trends in rates of International Classification of Diseases, Ninth Revision-coded ambulatory visits and antibiotic prescriptions attributable to acute otitis media were evaluated, and the national direct medical expenditures for these outcomes were estimated.RESULTS. In a comparison of 2004 with 1997â1999 (baseline period), rates of ambulatory visits and antibiotic prescriptions attributable to acute otitis media decreased from 2173 to 1244 visits per 1000 person-years (42.7% reduction) and from 1244 to 722 prescriptions per 1000 person-years (41.9% reduction), respectively. Total, estimated, national direct medical expenditures for acute otitis media-related ambulatory visits and antibiotic prescriptions for children <2 years of age decreased from an average of $1.41 billion during 1997 to 1999 to $0.95 billion in 2004 (32.3% reduction).CONCLUSIONS. Acute otitis media-related health care utilization and associated antibiotic prescriptions for privately insured young children decreased more than expected (on the basis of efficacy estimates in prelicensure clinical trials) after the introduction of routine 7-valent pneumococcal conjugate vaccine immunization. Although other factors, such as clinical practice guidelines to reduce antibiotic use, might have contributed to the observed trend, 7-valent pneumococcal conjugate vaccine may play an important role in reducing the burden of acute otitis media, resulting in substantial savings in medical care costs.
Trends in Acute Otitis Media-Related Health Care Utilization by Privately Insured Young Children in the United States, 1997-2004 -- Zhou et al. 121 (2): 253 -- PediatricsTags: otitismedia
Sun, 03 Feb 2008 15:41:59 -0500 - Mark is still dead
Last week I wrote about Mark.
Unfortunately - the bad dream that he had died wasn't a dream - and it's been a surreal week - re-connecting with old friends, and re-living formative memories.
Mark was a passionate, thoughtful person who worked so hard to make things RIGHT – while doing his best to have fun - with a unique serene yet sardonic demeanor.
In 1982, I was Mark’s apprentice for 12 months on the 144’ sailing ship – the Barkentine r/v Regina Maris – where he was Chief Engineer (El Jefe) – and I was the Assistant Engineer (El Lacayo) - earning $1 / day.
It’s Mark’s fault that I am a physician.
As we diagnosed, disassembled (and reassembled) diesel engines, bilge pumps, de-salinators and generators together – Mark taught me the fine art of diagnosis, decision making, and careful, patient action.
In healthcare we call this SOAP (Subjective Objective Assessment and Plan) – On Six Forks Road (and Toyota) – it’s called PDCA (Plan-do-check-adjust).
Medical Educators call it GNOME.
Regardless of the name/ framework/ religion we use – it’s about thinking carefully, calmly and strategically about where you want to end up – then having the knowledge, skill and attitude to get you there.
We're on our way to Mark's memorial service now. Marcie sent me this last night - which does a better job than I ever will in telling a short story about our friend:
Sat, 02 Feb 2008 09:02:50 -0500 - FeedSync
FeedSync - I wonder why I haven't seen much buzz about this. If Dave Winer had come up with it - would it be the cool new thing? It's going to take a while before we see Microsoft as an innovator - eh?Blogged with Flock
Thu, 31 Jan 2008 07:52:12 -0500 - Can we solve these problems with IT?
My fax machine has too many faxes in it every morning
Analog office: .. My fax machine has too many faxes in it every morningwhich my staff put on a pile on my desk and then I try to read them and act on them by scribbling illegible notes on them and putting them in piles on someone else’s desk.Digital office: My fax machine has too many faxes in it every morning .. which my staff scan into my EMR and then I try to read them, and act on them often using a separate system functionality – so need to leave the “reading” work stream, do the action, then return to “reading”Reassuring Lab Results just arrived (by fax, mail, local printer, etc)
When I get labs back – most of them are normal. I can:Initial them (digitally or pen/paper) and put them in the chart (paper or digital) Tell the patient that “no news is good news” (which is terrible customer service, BTW)But some will call (they should!)So the chart gets pulled (paper office)And someone calls them back (usually nurse)And sometimes answers the questionsAnd sometimes the patient still wants to talk with the providerSo now it comes to me Like 50 other onesI stay in the office until 8 PM calling my patients back And they ask other questions when we are on the phone Or they are not home so I leave a message So there is a loose end that I have to manage tomorrow.I am a specialist – seeing a new patient for the first time.
I don’t have any records – so my nurse or AA calls the referring provider, pharmacy (for medication list), and hostpial (for recent H & P/Discharge summary)I wait Some of it arrives via fax Most of it arrives tomorrow I call the preferring provider’s office.wait The provider comes to the phoneCan’t remember much about the patientAsks her staff to pull the chart We wait and talk about our kids in CollegeOur waiting rooms fill up with angry patients and well-dressed drug reps with too much cologneChart is “not found” – it must be in a big pile somewhereWe both get frustrated – referring provider hums a few bars from memory.We hang up. I make decisions with the patient based on incomplete dataI dictate my progress notesI sign them (barely review them) when they come back in 3 days from the transcriptionistThey go into the chart (digital or paper)My staff faxes a copy of my note to the referring provider.I am a provider writing a prescription for Clarinex
The patient has seasonal allergies
Has tried “everything else”
The drug reps left a pile of these and I gave some to the patient last time she was here
They work “wonderfully”
She wants more
So I write a prescription
Which she takes to CVS
And they want to charge her $107.50
Because it’s not covered
So she calls my office
And my nurse says she’ll work on it
So she gets the chart
So she looks up the insurance company (BlahBlah Healthcare)
And then she calls the “prior authorization” phone number
And waits on hold
Until a person answers
Who sends a fax
Which the nurse gets 4 hours later
And gets the chart again
And she fills out the form on the fax
And she puts it on my desk with a “sign here” sticky note on the signature line – and pointing to the (empty) justification section
I get it on my desk the next morning
I fill in the blank sections of the form and put back on the nurse’s desk
Who faxes the form …
3 days later the patient calls and asks if this is done.
Different nurse pulls the chart and sees the copy of the fax that was sent to the insurance company – so she says yes.
Patient goes to CVS who tries to charge her $107.50 again
Patient goes home and calls the office
Nurse pulls chart again
Nurse calls BlahBlah Healthcare. Turns out they haven’t processed it. They will process it and will let us know if it’s denied (They won’t let us know it it’s approved).
Nurse calls patient and tells her to try CVS again in a few days.
Patient gets angry and yells at nurse
Nurse was depressed anyway and quits her job – slamming the door on her way out, hitting a child in the head as he comes in for his 3-year well-child visit. He is conscious, but has a laceration on his forehead that will require repair. The kid’s mother says she’ll sue the physician “for everything he’s worth” as she drags the kid off toward the emergency room.
She hits a raccoon on the way home, barely missing an Oak tree as she tries to avoid little Rocky.
She calls her physician and requests some Xanax to “calm my nerves” – beginning a life of dependence on benzodiazepines and poverty. She stops making payments on her mortgage, loses her home, and was last seen living over a ventilation grate near the Misys offices in New York City.
Thu, 31 Jan 2008 04:58:35 -0500 - Mark
Mark died yesterday. What a jerk. He had an MI and died - and now Marcie (behind the pole next to Liz) has to clear out the barn and run the company and feed the dogs and be without him.
That's Mark holding on to the tent pole at my wedding in August 1989. He's talking with Richie.
Liz is helping Mark hold up the pole. When Mark got Married, Richie, Liz and I drove for 20 hours straight and got there 10 minutes late. Dead Mark. I hadn't seen him for a few years - but he was the kind of friend who I could call every 6 or 12 months and we would pick up the conversation right where we left off. Not any more I guess. :-( I'll miss you, Mark.
Fri, 25 Jan 2008 08:05:50 -0500 - JAMA -- Abstract: Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis: A Randomized Controlled Trial, December 5, 2007, Williamson et al. 298 (21): 2487
Neither an antibiotic nor a topical steroid alone or in combination was effective as a treatment for acute sinusitis in the primary care setting.
JAMA -- Abstract: Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis: A Randomized Controlled Trial, December 5, 2007, Williamson et al. 298 (21): 2487Blogged with Flock
Fri, 18 Jan 2008 05:52:23 -0500 - links for 2008-01-16
Tue, 15 Jan 2008 20:17:05 -0500 - 3rd UPDATE: Vytorin Fails To Benefit Artery Vs. Statin Drug
3rd UPDATE: Vytorin Fails To Benefit Artery Vs. Statin Drug Ouch. Yeh - I've not been so impressed with this medication either.Blogged with Flock
Mon, 14 Jan 2008 22:23:42 -0500 - Informatics Comeptency Evaluation
Let's say you want to evaluate the Medical INformatics Competency of a group of students, IT staff or physicians.
I'm working on an evaluation tool that should be EASY for anyone with these skills .. and a true challenge for those without.
Take a look at it here. It's a Google spreadsheet so you will have to log in to Google Docs to edit it .. but feel free to do so.
Sun, 13 Jan 2008 01:42:56 -0500 - Nasal Saline for Chronic Sinonasal Symptoms: A Randomized Controlled Trial
I've been recommending nasal saline to patients with sinusitis for a while - and this article provides a compelling argument for the use of a neti pot rather than the traditional "saline spray."
Use of neti pots has increased quite a bit lately - largely due to a clinical event known as the "oprah effect." Forget the RCT as a Gold Standard. If Oprah advises a clinical intervention - we all should hop on board.I usually intorduce the concept to patients by showing them the first 60 seconds of this video.
It's quicker to just ask "have you heard of a neti pot" and if the answer is "no", I flip my x61 screen around and show the video. Why irrigation works.
This just makes sense. If there is poo in your toilet - does putting clorox make it go away? Of course not - you need to flush. If there are boogers clogging your sinuses - will antibiotics make the boogers go away? Of course not - you need to flush.
I find that rather few of my patients request antibiotics now for the treatment of sinusitis symptoms. This is a good thing - since it's rather clear that only a fraction of patients with sinusitis benefit from antibiotics. Educating patients today will make things easier for everyone in the future. As we know - physicians overestimate patients' expectations for antibiotics in the first place - Here's a nice summary of the most recent practice guideline on sinusitis treatment. Note a few things:
- Most patients with sinusitis don't benefit from antibiotics. Antibiotics benefit only one of 7 patients they are prescribe to for sinusitis. 6/7 of patients prescribed antibiotics for sinusitis gain no benefit from the intervention, and 1 of every 9 patients prescribed antibiotics is harmed in some way by this treatment.
- Nasal irrigation is not a component of this guideline. We'll have to wait for the "post-Oprah" guideline in a few years. This cochrane reivew provides additional insight that saline irrigation is safe and effective.
- If antibiotics are used, there is little difference between medications re: efficacy. translation: don't use expensive broad spectrum agents. Amoxicillin is fine. For penicillin allergic patients, use TMP/SMX or erythromycin (250 QID will minimize GI side effects).
Tags: sinusitis saline neti pot
Fri, 11 Jan 2008 06:41:20 -0500 - Open Source, White Plains, Healthcare
Spent yesterday on the 8th floor at 123 Main Street for meetings with
Bob's team. He's got a great bunch of people together - and it is inspiring to be part of a team that's doing important work in a meaningful way. Working with a team of smart people who "get it" and are intrinsically motivated is always good to re-charge the batteries - much like I feel when I go to STFM meetings. That's saying a lot, I suppose, since I remain such an "I."
Olivier was among the participants - though he didn't speak up as much as I would have liked. Perhaps He's an "I" too. :-)
He did show me his Smartcard. Every French Citizen has one -
and they have had them for TEN YEARS. One wonders why we can't get even the easy parts right in the US. The reimbursement structure for health care here is so broken - and - like a virus - this permeates all of how we attempt to deliver health care. Our IT systems - from the EMRs to the practice management systems - need to be far more complex so that the even more complex billing proclivities can be managed by herds of people on both sides of the money: people I pay to GET it - and people the payers pay to DENY it. How dumb. When my office overhead is ~ 60% .. (this is typical in primary care) .. it means that more than half of the money we collect doesn't go to health care. Makes one think about other crazy paradigms of care delivery - eh? Maybe not so crazy.
The French Smart card is just an example of how a system just works as it should. Sure - Michael Moore's movie is a bit over the top - but he's right.
Of course he's right. I've been a member of PNHP for nearly two decades now (I hosted the website in my attic for its first few years of existence) and though I've been less involved in the organization lately - I remain convinced that we need to fix this problem with a single-payer solution. Intelligent use of technology - with patients at the center - will also help us to spend less time on the administrative chores - and more time on the important work of making thoughtful, evidence-based decisions with our patients.
Yes - WITH our patients - not for them:
In the 1970s ... studies began to show that patients with chronic conditions who are active in their own care have much better health outcomes. And yet ... doctors and patients are still stuck in ... "Marcus Welby mode" -- with the omniscient, paternalistic doctor ministering to the passive, nodding patient.
(From this Washington Post article)In Health IT - we need to practice precisely the same way: Understand best practice, educate our customer, and develop our skills, tools and partnerships in a manner that will help support them to the best of our ability. This is too important to treat it like a business. This is a profession - guided by important principles of equity, fairness, and benevolence.Tags: HealthIT Open Source
Thu, 10 Jan 2008 11:21:44 -0500
