Resident Work Hours- More Reform

OSHA (The Occupational Safety and Health Administration) has now entered the fray concerning physician resident work hours

Public Citizen, AMSA, and the  committee of residents and interns have sent a petition to the Secretary of  OSHA. Who signed the petition?

LiveJournal Tags: OSHA,AMSA,Resident Physicians,Work Hours,Health Reform,Healthtrain express,quality of care,ACGME

According to Katherine Matos writing on the health care blog,

The petition requests that OSHA exercise the authority granted under §3(8) of the Occupational Safety and Health Act to implement the following federal work-hour standard:

Previous attempts to do this were via the regulatory powers of numerous graduate medical education programs and their ‘guidelines’ from the Accreditation Council of Graduate Medical Education Programs, whose threat was the de-certification of a specialty program or an overall withdrawal of the institutions graduate medical education credentials.

This new and innovative approach reveals the growing influence of student doctors and young doctors at a national level.

Arguments have gone on for decades regarding the near ‘servitude’ in post graduate medical education programs.

Program directors and trained doctors have often used the argument that shortening resident work hours would greatly impact on their ability to follow disease states, and impair patient care by frequent transfer of their care to other residents.

Residents have argued that the long work hours impact on the quality of care, and studies have shown the error rate increased substantially with long work hours and lack of adequate sleep periods.

There have been numerous studies demonstrating the adverse effects of sleep deprivation in resident physicians.

JAMA,   NEJM, A Study performed at the Johns Hopkins University,

Mental Health

• One study described “house officer stress syndrome.” Caused in large part by sleep-deprivation and excessive work load, physicians-in-training may suffer from (1) episodic cognitive impairment, (2) chronic low-grade anger with outbursts, (3) pervasive cynicism, (4) family discord, (5) depression, (6) suicidal ideation and suicide, and (7) substance abuse.
• Four studies demonstrated that residents are unhappy, face high levels of stress, and suffer “major problems” in their personal relationships with others.
• Three studies demonstrated that on-call residents reported greater mood disturbance and increased negative mood than those who were rested.
• One study found that as many as 30% of residents experience depression during their residencies.
• A study published in the Archives of Internal Medicine found that 21% of residents reported depressed scores on the Center for Epidemiological Studies-Depression (CES-D) scale and that depressed responses increased with longer work weeks. Two other studies also found increased rates of depression among residents that correlated with high work hours.

Pregnancy

• A NEJM study reported that premature labor and preeclampsia or eclampsia was twice as common among pregnant residents as the wives of male residents and that residents working more than 100 hours per week in the third trimester were twice as much at risk for preterm delivery than those that worked fewer than 100 hours.
• The pre-term labor and preeclampsia risk was validated by a study published in Obstetrics and Gynecology.
• One study found that infants born during residency significantly more likely to be born with intrauterine growth restriction.

Percutaneous Injuries (such as needlestick injuries)

• A JAMA study of self-reported percutaneous injuries in residents found that substantially increased risk during day shifts after overnight call as compared with day shifts not preceded by overnight call.
• “An Annals of Surgery study from 2005 found that 20 to 38% of all procedures in one urban academic teaching hospital involved exposure to HIV, HBV or HCV.”
• A NEJM study found that 99% of all residents had suffered a needlestick injury by their final year of study. Fatigue was the second most common reason given for the injury.

The Response from OSHA thus far:

‘A clear shot over the bow of current resident work hours.

A large part of this article is quoted from The Health Care Blog

New venue

I was busy the past several days working on relocating health train express onto a new ‘track’.  I had some difficulties transporting images from my present location, so health train express will remain on this track while I resolve some ‘geek’ issues.

President Obama is beginning another round of promoting ‘Obama care”.  Public opinion is overwhelming against the overall scope of reform..  Today’s Wall Street Journal Blog focuses on this,

“Health Care on the Agenda: Following mid-term elections, the Obama administration this week will once again focus on pushing the overhaul of the health care system, with the president giving a health-care speech on Wednesday, reports the WSJ. Public support has continued to wane, particularly in light of unpopular moves like some insurers saying they must raise premiums well beyond the anticipated 1% to 2%. Some provisions of the law take effect this week, including the one allowing young adults to stay on their parents’ plan until age 26.”

No doubt he has heard the rumblings from the outcome of primaries this past week.  

What is interesting in the above commentary is that the insurers were at the table of reform machinations, and now have backtracked on their estimates of the increased cost to them caused by health reform.

Stay tuned…………..

LiveJournal Tags: obamacare,health train express,wsj,reform,primary elections

Pew Internet Project

 

The Pew Internet Project's Susannah Fox discusses the research group's latest healthcare findings at Health 2.0. Europe. The Pew Internet project is a non-profit research organization based in Washington DC that studies the social impact of the internet.

 

 

She elaborates on several patterns of usage for patients with chronic diseases, diabetes, cancer, lung diseases, hypertension and those with acute illness.  Patients with chronic diseases are more likely to see or ask a health professional.  Only 62% of patients with chronic illness seek advice from the internet, while 82% of healthy individuals seek advice from the internet. 93% of those with chronic illness seek their health from health professionals rather than the internet.

Patients seek knowledge from each other, via blogs and sites such as  ‘People Like Me”, listservs, rather than health education websites.

The internet is a supplement to health care and has been over-rated as to it’s importance.  Further development is necessary.

Watch the video .

LiveJournal Tags: health 2.0,health train express,Pew Internet Project,Susannah Fox

Reviewing the Past

Yesterday I was privileged to witness the growth of our Inland Empire Health Information Organization. After one false start five years ago it now will happen.   Bottom line,  you just follow the money and the open pocketbook of the U.S. Congress (your taxpayer dollars)

I had been away for almost five years after planting a seed for the development of this important initiative.

Five years ago when David Brailer MD was head of ONCHIT few knew what was being planned nor what would come to fruition.

For those who want to look at some of those days click here…..

I don’t really remember writing some of these blogs , but this one was particularly funny (at least to me)

After a long hard search I found my original blog post announcing the formation of the Riverside Regional Health Information Technology Group  WHAT WAS I THINKING??? circa February 2005 (over five years ago)!!!

Health Information Exchanges and Electronic Medical Records Part II

 

Part I in my previous blog   ………………

 

I describe HITECH and APPA and the negative reward system to create incentives for physicians and hospitals to acquire and use electronic medical records.

 

Today I am going to describe several critical and key issues which will greatly impact on providers in their daily work.

Here is the scenario.

Dr Gofaster is an internal medicine physician who attends patients at two different hospitals, BeHospitalized Medical Center and Don’tbeAdmiited Center for Cardiac Arrest.  He is on call for both E.Ds

His iPhone do it all sounds an alarm and he receives an SMS from BHMC E.D. Dr Gofaster sees the patient and records his EMR for patient  I.Dont Wantadiehere.  Following admission the next day he sees his patient but is unable to see the ED notes because the outpatient system is entirely different and not connected to the inpatient EMR. (my experience in the federal US Army AHLTA system.)  He experiences some difficulty using the two differing systems in one hospital.

 

Dr Gofaster’s iPhone do it all goes off again summoning him to the ED at DBAMC.  He arrives in five minutes, sees the patient and has a problem using the entirely different EMR in the second ED.  After admission he goes to the floor and sees another inpatient. He is again stymied using the inpatient EMR since it is different from BHMC.  He either forgot his password or left it in his wallet in the car.

Summary,  two different hospitals,  Four different EMRs

Four different passwords that require changes every 90 days.

Dr Nowslowingdownmore attempts to enter his password incorrectly three times in a row…the system now tells him he is locked out and he must answer 4 challenge questions, which  he cannot remember nor answer.

  His alternate choice is to dial 1-800-IDONT-SEE-PATIENTS, he is placed on hold after answering four voice mail prompts,  #,@,!,&,&  unless it is on the weekend when he must enter at least 1 number,  one  upper case letter, one lower case letter, and be no less than ten digits long.

Upon contacting a support specialist (who is in Singapore) he is asked what version is his hospital software.

Thirty minutes later he is  ready to record his EMR.  As he logs in the log in page announces that the system is down for the next 4 hours for maintenance, with the message. “We are sorry to inconvenience you, doctor.

Dr Nowslowingdownmore heads to his office and starts his workday in the office.  He enters the first patient room. Patient

I.Wantagohome is pacing because he needs to leave (he is an attorney)  Dr N. Slowingdownmore attempts to log in his office system, but receives a message

he must change his password and he cannot use any of his old passwords.  He is locked out while attempting to answer two of his six alternate secret questions and answers.

 

Dr N.Slowingdownmore gives it up and pulls out his trusty No.2 yellow pencil and waits ten minutes while Betsy tries to find a progress notes sheet (they are buried under some old floor mops in the storage room).  Dr. Slowingdownmore notes that his pencil has never been sharpened and their are no pencil sharpeners, so he pulls out a scalpel  blade to sharpen it.  In the process he slices the tip of his index finger on his writing hand off.

Dr. S swears loudly, throws his iPhone against the wall, shattering it as it falls to the floor. 

His medical assistant  Suzie Icantakeitanymore brings in a certified letter from the medical staff office placing him on probation due to his incomplete hospital  charts.

Get the picture, all you do-goody HIT folks and Politicos???

Names have been changed to protect the guilty.

Health Information Exchanges and Electronic Medical Record Negative Reward Incentives

 

 

Health Information Exchanges and Electronic Medical Record Negative Reward Incentives are still controversial. The American Recovery and Reinvestment Act includes a wide variety of mandates, including HITECH to stimulate acquisition of EMR and building a national health information exchange network.

As a student and consultant of health information exchange development and the federal and state government incentives for ‘rapid’ development’ of medical digital records, I am struck at the lack of organized medicine’s and individual practitioners opinions regarding EMRs.

Congress has been sold a ‘bill of goods’ much like buying the Brooklyn Bridge for $1.00. (And the price will go up next year if you don’t buy it now). This is very much snake oil medicine, at its worst.

Let me be clear about one thing.  I am not anti-EMR or anti-HIE development.  The present developmental plans benefits mostly health information technology vendors

I am not a Luddite, by any means, however from all the information I have been able to gather, there are few if any  studies that document meaningful return on investment.

This “catalytic innovation”, a term which I coined five years, ago is a disruptive technology.

Physicians and patients should contact our senators and representatives in Congress and at the state level to change the formula for incentives. The EMR products offered to physician practices and consumer electronic health records,  are not mature enough to invest billions of dollars at the taxpayer’s expense. The timeline is defective in several ways.

1. Evaluation, study and implementation also require training time.

2. The HIT industry does not have the manpower and/or resources to accomplish this within the specified time period.

3. There has been very limited success for practitioners and hospitals to adopt EMR.

4. The impact of the health reform legislation has yet to be determined on the overall cost of health care. Numerous early studies indicate the cost to the consumer will rise substantially with health reform. Certainly the stated goals are admirable for our society. Early indicators are that the insurance industry will do it’s best to maximize profit during the early years of health reform as a hedge against future legislation requiring expanded coverage of benefits and the mandates from the states to eliminate the ‘uninsured’. States are not in the health care business and previous experience with major risk policies reveals that States depend upon private insurers to manage and indemnify the policies and operate Medicaid and Medicaid HMOs. The same market forces will continue to impact the model and many insurers will refuse to offer these policies or drop contracts with the state.

5. It will require several more years prior to penalizing those who do not adopt EMR, when the current  products of choice are inadequate, and based upon old models of billing and collections.

6. Certainly if the stated goal of medical homes as well as non-procedural reimbursement methodology the present plan is not in line with the goals of increasing efficiency, nor collecting meaningful information. Our currently available EMR  systems address neither the purported goal of meaningful data for individual practices, nor promoting best outcomes. The current Gantt chart time line will  stimulate the acquisition of poorly designed clinical information systems.

7. The term meaningful use (for whom?) is inadequate and is not defined in terms of the differing type of practices, or hospitals.

more……in my next blog post.

 

LiveJournal Tags: emr,meaningful use,health information exchange,health reform,emr incentive,health train express

Rising Stars in Health Reform

Sermo has arisen in the past three years as a powerful media voice for the grass roots of physicians.

FOR IMMEDIATE RELEASE

Sermo Named to Fast Company Magazine’s List of World’s Most Innovative Companies

Largest Physician Community Recognized as ‘Political Force’ Behind Healthcare Reform Efforts

Cambridge, MA, February 24, 2010 — Sermo (http://www.sermo.com), the world’s largest online community for physicians, today announced it has been named to Fast Company Magazine’s list of the world's most innovative companies. Sermo earned its ranking for providing a free web service – referenced by Fast Company as a ‘facebook for doctors’ - where physicians can collaborate and improve patient care. The company was also cited as a ‘political force’ after 11,500 physician members composed, signed and delivered a petition opposing the American Medical Association's acceptance of the House healthcare reform bill in the summer of 2009.

To create this year’s list, Fast Company’s editorial team analyzed information on thousands of businesses across the globe to identify creative models and progressive cultures. Sermo was recognized alongside the most respected healthcare innovators in the world, including athenahealth, GE, Cisco, Patientslikeme, and Kaiser Permanente.

“Since launching in 2006, more than 20% of all US physicians have joined the Sermo community,” said Dr. Daniel Palestrant, CEO & Founder of Sermo. “As the physician community has grown, so too has our client list, which now includes 10 of the top 12 pharmaceutical companies. These companies are engaging physicians through our social media offerings built specifically to increase brand awareness and provide valuable market intelligence not possible through other channels.”

Unlike other models, Sermo is free of advertising and free to physicians. Revenue is generated as clients purchase products to interact with specialists. To learn more about Sermo’s social media offerings, visit www.sermo.com/clients.

The complete Fast Company Most Innovative Companies list and related stories appear in the March 2010 issue of Fast Company magazine, on newsstands currently and online at www.fastcompany.com/MIC.

About Sermo
Sermo is the largest online physician community, where over 112,000 physicians collaborate to improve patient care. Sermo provides access to its community for clients that need fast, actionable insights into treatments, drugs and devices. Learn more at www.sermo.com.

Of some interest is the fact that Sermo and the AMA originally were in a partnership which dissolved within the first  year of their agreement.  Sermo’s contention is that the AMA does not truly represent any majority of American Physicians and  has a conflict of interest in holding the copyright for the CPT codes.

 

Another embryonic politically active forum is Docs4Patientcare.org   This organization abruptly sprouted last year during the health reform debates. For more information go to their website. 

Health 2.0 International

Please click to expand to fill screen

 

 

Medical Social Networking has gone global, from the U.S. to the U.K. and beyond into specialty societies.

A quick google search will bring up many social networking sites, some with authentication required, membership requirements,and also open networks.

The Elephant in the Boa Constrictor

Richard Reece M.D. who writes Medinnovation Blog aptly analogized HIT  and the Government. 

The Elephant in the Room

Before resigning in frustration as the first “HIT Czar,” David Brailer observed in a 2005 in a New Times Times interview , “The elephant in the living room is what we’re trying to do is the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.”

The Blind Men and The Elephant

The second metaphor is the Blind Men and the Elephant. Our health care system is an elephant. Everyone feels the elephant’s parts differently. Doctors hanging on to the tail feel the system is an encircling rope, purchasers touching the leg feel it is an immovable tree, plans holding the trunk feel it is a squirming snake, and government officials riding on the head feel it as a global positioning satellite devices, capable of controlling the direction of the elephant.

 

As Dr Reece so eloquently espouses:

“What concerns me is what will come out the distal end of the boa constrictor once the digestive process ends.”

Certification Central

The ONC has announced the approval of both CCHIT and the Drummond Group as agents for certifying interoperability and other standards for EMR.  Both groups fulfilled the requirement of the ONC and the NIST.

 

This ruling should bring much relief to CCHIT and those vendors who have participated willingly and volunteered to develop and test the standards. CCHIT has been in operation since 2006.

 

Some were critical and concerned that CCHIT represented mainly vendors, while the Drummond Group would be more unbiased. Competition is always a good thing, and should enhance affordability for those vendors seeking certification for EMRs.

This is another ‘elephant for the boa constrictor to swallow.

 

Extra Extra Read All About It

Today’s online edition of the New England Journal of Medicine has two articles, one by Katherine Sebelius regarding the recent health reform legislation in the United States, and another article  by Nick Black, M.D. on the United Kingdom’s proposed  changes to the NHS.

The appearance of these two articles with almost inexplicable timing  reveals how two different systems see themselves as failures and are seeking to correct it by going in opposite directions. 

It begs the question, “Who is ahead in creating a ‘more perfect world?”

So goes California…so goes the Nation

or why we need less government.

The remainder of this post has been removed at the request of the copyright holder. Modern Medicine holds the rights to the content, and we are negotiating with them to license some portions of their material for this blog. Sorry.

Power to the People !!???

What people you may ask?  Ask and ye shall be told !!

Modern Medicine announced today the 100 MOST POWERFUL PEOPLE IN MEDICINE.

So, who makes  this momentous decision?? Is it more important than the ‘Golden Llama Award’?? (of which I unashamedly boast that I earned some time ago)

A little bit of research reveals that these mighty Centurions are chosen in this manner. 

Is it any wonder why most physicians are enraged and stand gawking with disbelief?

Dr Wes, in his blog today points out how the rules don’t count for those who make the rules

Should Dr. Emanuel not have noted his relationship as White House advisor for health care policy and his relationship with his brother, White House Chief of Staff Rahm Emanuel? And should Ms. DeParle's disclosed her role as President Obama's so-called health czar with significant ties to private equity firms?

Conflict of interest exists when an author, editor, or peer reviewer has a competing interest that could unduly influence (or be perceived to do so) his or her responsibilities in the publication process. The potential for an author’s conflict of interest exists when he or she (or the author’s institution or employer) has personal or financial relationships that could influence (bias) his or her actions. These relationships vary from those with negligible potential to influence judgment to those with great potential to influence judgment. Not all relationships represent true conflict of interest. Conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific judgment.
Authors, editors, and peer reviewers must state explicitly whether potential conflicts do or do not exist. Academic, financial, institutional, and personal relationships (such as employment, consultancies, close colleague or family ties, honoraria for advice or public speaking, service on advisory boards or medical education companies, stock ownership or options, paid expert testimony, grants or patents received or pending, and royalties) are potential conflicts of interest that could undermine the credibility of the journal, the authors, and science itself.

Perhaps such disclosures only for the little people in health care who try to publish their work.

 

And finally  Dr Wes offers this list as the 10 most important (and powerful ) people in Medicine:

So who are the most powerful people in health care?
Well, I'd like to propose my list - maybe not of a 100 people (frankly, nothing gets done if you have a committee of 100 people anyway) - but rather my own list of the Top 10 Most Powerful People in Your Health Care today:

10. The Doctor - They consider the differential, write the orders, follow-up on tests, and move the health care ball forward throughout your hospitalization or stay with a rehab facility. As such, they should be given their power due, even if many other members of the health care team are actually are the ones that make sure the care happens. Still, because the doctor gets most of the liability risk if things don't happen or happen incorrectly, they just make my power list.
9. The Food Service Personnel - These folks are powerful. They have the ability to make even a clear liquid diet look like real food - especially when they mix the colors and flavors of jello. Further, proper parenteral nutrition for an ICD patient greatly shortens the sickest patient's hospitalization. Get it right and everyone benefits. Power personified.
8. The Physical Therapist - If you can't eat your food, sit up, keep your muscles toned, maintain the range of motion of your limbs when sick, the chances of returning to independent living are limited. Physical therapist have come of the most helpful techniques to get going - both physically and mentally - like turkey bowling. Their power over our patients should definitely be appreciated more.
7. The Social Worker - Want to negotiate the complex Medicare and Medicaid rules for placement in an assisted living facility? Need to get a patient to rehab? Want to arrange transportation for a patient that doesn't have a penny to their name? Make something from absolutely nothing? Call the Social Worker - but call them early in the hospital stay. (They're never at their best with last-minute consults.)
6. The Nursing Supervisor - Trust me on this. No one has more power to assure adequate staffing on each patient care ward each day than the Nursing Supervisor. Medical students and residents that cross the directives issued by this individual do so at their own peril.
5. The Bed Coordinator - If you need to admit a patient to a hospital, they must first get a bed. With many hospitals working at or near capacity, no single person has more influence over the patients admitted to a hospital facility. They find beds when no one else can. After all, it's their job.
4. The Hospital Operator - Name one person who can activate a Code Blue (cardiac arrest), find the obscure specialist in the middle of the night when they're most needed, or mobilize a trauma team faster. Can't do it? That, my friends, is power.
3. The Night Shift Nurse - At three in the morning when you're lying there in the hospital bed and need something - anything - who's the most important person in the hospital who will assure you're needs are tended to? Need I say more? If the night shift nurse is inattentive, unresponsive, irresponsible for that 8-hour shift - you're screwed. On the other hand, if she's attentive, knows when to call for help, or provides pain relief when you need it most after surgery, or - most important - gives you that laxative at 3AM - his or her power in medicine pales in comparison to any bureaucrat, politician, or hospital system CEO.
2. The Patient's Family - Often forgotten, family members have huge influence over the care provided to their loved one - especially at times where their loved one might not be able to communicate. This power should not be ignored, but it cuts both ways, too. While family members can facilitate the treatment and rehabilitation of their loved one because they know them better than anyone else, they can also prolong undue suffering if they do not comprehend the limits of care that their loved one desires in the end-of-life setting. Families that communicate their needs and wishes before anyone gets sick avoid much of the confusion during this difficult time and serve as powerful allies to the health care team.
1. You, The Patient - No one has more influence and power over their care than you. Don't want care? Leave. No one can stop you. Want care and don't have a penny? Come to the Emergency Room. You won't be turned away. Wonder what all the big buildings, waterfalls, and fancy technology were built and bought for? You. Every single person involved in health care is there because of you. So make the most of it. Come prepared. Know your medical history, medicines and allergies. If you can't remember, keep a list with you. Ask questions. Insist on clear answers. Work with your care givers, don't fight them. If you're not sure, get a second opinion. Write a letter acknowledging those that made the extra effort and scolding those that didn't. Your constructive criticism makes the system better. And know that hospitals understand the importance of your word-of-mouth referral - it's the most powerful marketing strategy a health care system can generate. Finally, remember that you can vote for politicians that don't forget who's in charge. You are the ultimate power broker in health care. Don't forget it.

-Wes

Musings of a cardiologist and cardiac electro physiologist.

And Thank you to the most powerful electophysiologist in the blog world….make my milliamps…Dr Wes

LiveJournal Tags: modern healthcare,Dr Wes,conflicts,healthtrain express