ACA Without Meaningful Use = Failure

Healthcare be damned, full speed ahead for rationing. The author of this healthcare blog did not state it this way, but he should have. I have had the suspicion that patient engagement was not intended and Adrian Gropper, MD at least states this. Most physicians don't want patient engagement in the first place just like they do not want patients to have access to their electronic health records (EHRs) as I stated in my blog here.

Dr. Gropper had this to say about patient engagement, “Not surprisingly, patient engagement is an afterthought (talking about EHR).” Then he continues, “Patient engagement, from a health economics perspective, is incidental in care coordination but essential in avoiding the perception of rationing.” Ouch, the perception of rationing when rationing is planned. Many Medicare and Medicaid patients are already feeling the pinch of rationing as Accountable Care Organizations (ACO) and hospitals are attempting to make their funds stretch and grow their profits.

This statement is also worth quoting, “By paying ACO institutions instead of individual service providers, health insurance companies and Medicare provide direct economic incentives to reduce waste, lower costs and, if we’re not careful, withhold needed care. An ACO is by definition an organization or institutional construct.” Bold is my emphasis. “The book on patient engagement is yet to be written. EHRs still treat patient engagement as a liability and state health information exchanges (HIEs) are still being designed without any patient engagement at all. (Opt-in and opt-out is still as far as they go.) Both EHRs and HIEs still perceive strong privacy principles and fair information practices as obstructionist.”

At least Dr. Gropper recognizes the changing landscape and the need for stronger doctor/patient relationships. He acknowledges that patients and doctors need our Internet-age tools in a form for privacy and communications. Patient engagement is a euphemism for communication and I personally don't like the obtuse way they express this. Patient engagement is also used to describe meaningful use.

Dr. Gropper concludes by saying, “Let’s start by making sure our data can be liberated from the various EHRs via Blue Button Plus (see explanation below) and that every federally certified HIE includes provisions for a patient-accessible EHR Record Locator Service. These are the foundation of patient engagement (meaningful use) and essential to the success of the Affordable Care Act.

Blue Button Plus is a blueprint for the structured and secure transmission of personal health data on behalf of an individual consumer. It meets and builds on the view, download, and transmit requirements in Meaningful Use Stage 2 for certified EHR technology. Read more about this at this link.

No, You Don't Want Shingles

If you have not had chickenpox, you have no worry about having shingles or herpes zoster. If you are one of the people that has had chickenpox, then please consider obtaining the vaccination for herpes zoster if your are age 60 or older. Anyone that has recovered from chickenpox may develop shingles; even children can get shingles. However, the risk of disease increases as a person gets older. About half of all cases occur among men and women 60 years old or older.

People who have medical conditions that keep their immune systems from working properly, such as certain cancers, including leukemia and lymphoma, and human immunodeficiency virus (HIV), and people who receive immunosuppressive drugs, such as steroids and drugs given after organ transplantation are at greater risk of getting shingles. People who develop shingles typically have only one episode in their lifetime. In rare cases, however, a person can have a second or even a third episode.

Shingles occurs when the virus that causes chickenpox starts up again in your body. After you get better from chickenpox, the virus is dormant in your nerve roots. In some people, it stays dormant forever. In others, the virus "wakes up" when disease, stress, or aging weakens the immune system. Some medicines may trigger the virus to wake up and cause a shingles rash. It is not clear why this happens, but after the virus becomes active again, it can only cause shingles, not chickenpox.

Shingles is only contagious during the time when the rash is in the blister-phase. A person is not infectious before blisters appear. Once the rash has developed crusts, the person is no longer contagious. You are unable to catch shingles from someone that has shingles. They can only spread the virus to another person who has never had chickenpox and who has not had the chickenpox vaccination.

Often the rash occurs in a single stripe around either the left or right side of the body. The rash can occur on one side of the face. Less often, the rash may be more widespread and look similar to a chickenpox rash (normally among people with a weakened immune system). The dangerous part of shingles is when it affects the eye and this can cause loss of vision.

Other symptoms of shingles can include fever, headache, chills, and upset stomach. If you have shingles, keep the rash covered, do not touch or scratch the rash, and wash your hands often to prevent the spread of the varicella zoster virus. Until your rash has developed crusts, avoid contact with pregnant women who have never had chickenpox or varicella zoster virus. Also, avoid contact with all children and anyone having a condition in the second paragraph above.

If shingles develops a complication, this is called postherpetic neuralgia (PHN). People with PHN have severe pain in the areas where they had the shingles rash, even after the rash clears up. This pain from PHN may be severe and debilitating, but it usually resolves in a few weeks or months in most patients. PHN can, however, persists for many years in some persons. The older you become the more likely you are to develop PHN. Occasionally shingles can lead to pneumonia, hearing problems, blindness, brain inflammation, or death.

This is a good reason to have the shingles vaccine (Zostavax®). This was recommended by the Advisory Committee on Immunization Practices (ACIP) in 2006 to reduce the risk of shingles and its associated pain in people age 60 years and older.

Your risk for developing shingles increases as you age. The vaccine is currently recommended for persons 60 years of age and older. Even people who have had shingles can receive the vaccine to help prevent future occurrences of the disease.

Shingles vaccine is available in pharmacies and doctor's offices. Talk with your healthcare provider if you have questions about shingles vaccine.

August Calendar of Monthly Events – Part 2

Part 2 of 2 parts

This is my favorite part of August awareness month, Medic Alert Awareness Month. There is an abundance of information that we need to be aware of when it comes to the reasons for wearing medic alert jewelry. While I generally blog about this from the diabetes perspective, there are many diseases and medical conditions that would be greatly helped if those patients would wear medic alert jewelry.

Even seniors should consider a form of medic alert. Then if you are a senior, how much can you afford to pay on a monthly basis or will your children be paying for this? I am not saying this is the best available, but check out this link. Not only do they have a system similar to a realtor key system to prevent emergency personnel from breaking in, but they also have medical information available and this can save time as well and get you the right treatment. I would urge every senior to explore the site, as it could be a lifesaver.

Medic alert jewelry is important for many conditions and diseases and will alert first responders to your condition or disease. This is also available to the hospital emergency department and other medical staff if necessary. Normally with medic alert jewelry, it can be worn by all family members needing this and can provide information relating to care wishes and information about the illness when the number on the jewelry is called.

And yes, most every first responder or emergency medical personnel know to look for this when assessing a patient. There are always a few know-it-alls that will ignore medic alert jewelry, but they seldom remain on the job long as their fellow first responders do not want them around for liability reasons. They also are often banned from working when they are discovered ignoring medic alert information as they have been trained to look for medic alert jewelry and make that phone call.

Some of the information available includes:

#1. Emergency Medical Information Record – this is a personal health record stored in our secure electronic database and accessible to first responders in emergencies. This includes information for adults, kids, essential information including family members to be notified, safe return information for people with early Alzheimer's or other dementia, and advance directive management.

#2. Emergency response available 24/7 so the attending physician or EMT can call a MedicAlert agent to obtain your treatment protocol or response plan.

#3. Family notification 24/7 by MedicAlert agents to designated family members or friends you wish to be notified.

I have written several blogs previously about this topic. One of the most read is this one about the pros and cons of the different types of jewelry. Surprisingly, the second popular is this one about medical tattoos. These are mostly useless if you are unable to talk as you have few of the medic alert benefits and no phone numbers for first responders to call or physicians to call for medical information. Yet, it seems the “in-thing” for many young people that don't understand the importance of medic alert. There are many people selling other items to alert people, but none that I have found that have the information to back them up. Occasionally there is a telephone number for the doctor during the day or office hours, but nothing for other medical information.

Two other blogs include this one and this one. If you are a person subject to hypoglycemia and hyperglycemia, you may wish to consider the one above for seniors where a press of the button will summon help. This could be extremely important if you live alone or spend a lot of time alone in your residence.

August Calendar of Monthly Events – Part 1

Part 1 of 2 parts

August has two events for our eyes. The first is Children's Eye Health and Safety Month and the second is Cataract Awareness Month. I will start with children as they need out attention. While most children most often have healthy eyes, there are some things that you as a parent should be on the watch for. This is particularly true if you have had some of the problems as a child.

It is important to set up regular pediatric appointments and vision testing should start no later than by age three. Parents should be aware of signs of vision problems about this time also. First, here are some easy things to watch for and should have the pediatrician check for if you have noticed any of the following:

#1. Amblyopia (lazy eye)

#2. Strabismus (crossed eyes)

#3. Ptosis (drooping of the eyelid)

#4. Color deficiency (color blindness)

#5. Refractive errors (nearsightedness, farsightedness, and astigmatism)

The parents can discover some of the above by watching for them. If you have a family history, be on the watch for these, as you will know them. Also be on the watch for disinterest in reading or viewing distant objects (near or farsightedness). If you child is squinting or turning their head in an unusual manner while watching television and especially if there in a disinterest is watching television or a movie with the family.

Use this month to discuss the importance of eye safety with your children. More than 12 million children suffer from vision impairment, and eye injuries are one of the leading causes of vision loss in children. There are an estimated 42,000 sports-related eye injuries each year and the majority of them happen to children.

Children should:

• Wear protective eyewear while participating in sports or recreational activities.
• Play with are age-appropriate toys. Avoid toys with sharp or protruding parts.

One of the best ways to ensure your child keeps his/her good vision throughout life is to set a good health example. Come on parents, you can do this.

Cataract Awareness Month is a good time to check with your eye doctor and have yourself checked out if you are over the age of 40. Some say this is fifty, but as important as eye health is, the sooner, the better for your vision. Even though much of the literature is trying to change this from August to June per the Prevent Blindness America organization, the calendars still list August as the month.

Having a cataract is a clouding of the eye’s lens which blocks or changes the passage of light into the eye. But unlike many eye diseases vision loss due to cataracts can be restored. Cataract surgery is one of the most commonly performed procedures in the United States and has a 95 percent success rate. A study has found that cataract surgery patients had a significantly reduced rate of hip fractures from falls.

Having a cataract in one or both eyes generally does not cause pain, redness, or tears. These changes in your vision may be signs of cataract, and I urge you to be check out if you have blurred vision, double vision, ghost images, the sense of a "film" over the eyes. If lights seem too dim for reading or close-up work, or you are "dazzled" by strong light. If you are changing eyeglass prescriptions often, I would wonder if your doctor is failing you by not checking for cataracts, because you may notice that the change is not helping your vision. Lastly, you may notice a cataract as it may appear as a milky or yellowish spot in the pupil instead of the normal black.

Do not be afraid to ask that the eye doctor check you for cataracts, as most eye doctors do check and can tell you if there is any concern. Both my ophthalmologist and optometrist have warned me to have this checked at every visit as they could see an indication, but that it was too early to do anything yet.

National Immunization Awareness Month (NIAM) is important. I have had several immunizations in the last year and will have at least one more in the coming year. My veteran's administration doctors stay on top of this and keep a calendar for me, thank goodness. And in 2004, when I was doing a fair amount of overseas travel, I needed to have a lot of catch up immunizations.

During the month of August, state and local public health departments across the country will be promoting back-to-school immunizations, encouraging college students to catch up on immunizations before they move into dormitories, and reminding everyone that immunizations are needed through adulthood.

NIAM activities are coordinated by the National Public Health Information Coalition (NPHIC) with assistance from the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases. They are preparing a toolkit on immunizations. “The toolkit is structured to help you communicate about immunizations for a different population each week of the month:

• Week 1: Back to school (children)
• Week 2: Off to college (young adults)
• Week 3: Not just for kids (adults)
• Week 4: A healthy start (babies & pregnant women)

The toolkit contains a number of resources for each week:

• Key messages (including social media messages)
• Sample news releases and articles
• Suggested events and strategies”

Please be sure to review your immunization schedule and bring your immunizations up to date and stay healthy.

The Destruction of Medicine

In my previous blog, I covered some of the problems doctors have in working through emotions and being human with patients. In this, I am now concerned that technology is being rejected by doctors because of the poor experience many are having with electronic medical records (EMR) or electronic health records (EHR).

In this case, I fear that we have an elitist doctor trying to make other doctors feel unimportant. Why else would he promote replacing clinicians with algorithms? Yes, we have doctors in diabetes doing just that and claiming that their algorithms are very comprehensive. So why did they need to issue a consensus statement to clarify the algorithms? I'm betting because they realized that doctors were not going to pay attention and ignore their precious diabetes algorithms.

Eric Topol is the Editor-in-Chief of Medscape which published his own article. The Creative Destruction of Medicine, named for the book he wrote, says, “I'm trying to zoom in on critical aspects of how the digital world is creating better healthcare.”

Now, if he is saying that algorithms and other digital applications will become tools to aid doctors, he is on the right course. Doctors that refuse to adapt and ignore useful tools are making life more difficult for themselves and their patients. There are some extremely useful tools now available, but they have not gained wide acceptance or use. The FDA has approved some and is working to approve more, but this is more time consuming than many are aware of to insure the accuracy and safety of these tools.

One type of tool is available to monitor patients' hearts. But this requires a monitoring center to monitor the device and report heart irregularities to the right doctor. Many doctors are not using this because CMS is not properly reimbursing for the time involved. Maybe the “chronic care fee” will make more use practical. Many devices are of the remote patient monitoring (RPM) type and this may also make them more useful and practical.

Dr. Topol is not one to avoid controversy, but he does list some tools that may make doctors more efficient. Hospitals are another question, as they seem interested only in expensive and complicated equipment, not tools that will increase efficiency. The tools presently available are efficient and do their tasks remarkably well. This is just the beginning and it is still threatening to physicians.

It may be that with more efficient physicians, the physician shortage may not be as severe as originally thought. Physicians will need to adapt and their practice will definitely be more demanding with them relying on people using the tools and the monitoring centers moving to the “medical home.” In other words, the doctor's office of today will be different from the doctor's office of tomorrow.

Are Your Doctor's Feelings Getting In the Way?

Sir William Osler, the founder of modern medicine has been the topic of more blogs and articles the last few weeks. I think I have figured out why. It is because of the principles he taught are coming under attack and some are not overly happy about this. This Medscape article credits Osler with, “The historical model that has been for physicians to remain cool, calm, and collected at all times. Your approach is to be strictly scientific: logical, objective, methodical, precise, dispassionate, the very embodiment of the term "clinical." This, medical tradition has it, is in the best interest of doctors and patients alike.”

In medicine today, patients are not as kind with this type of an attitude by their doctor and want to the doctor to be able to empathize with them and honestly answer questions rather than avoiding the question or answering only part of the question. In other words, this attitude of detachment can be a double-edged sword. While this will insulate and protect you from the powerful emotions displayed by patients, and protects patients from your emotions, is this a good thing?

A detached attitude can insulate the doctor and prevent the doctor from empathizing with patients. A doctor/patient relationship may technically exist, but that is the extent of it. The doctor will talk in a language that is over the patients' heads, but mistakenly assumes that the patients understand what is said and keeps the doctor on schedule. Research now shows that this often has a negative impact on clinical outcomes and the patients are most unhappy.

This doctor detachment is not a switch that can be turned on and off when desired. The detachment seeps into their relationships and then the physicians become detached from the world around and even from themselves. This is unhealthy for physicians and patients alike. Then the pent up feelings may lead to burnout. Cardiologist, Seth Bilazarian, MD, defines burnout as a physical or mental collapse caused by overwork or stress.

What also hurts and makes it difficult for doctors to express emotion is the pedestal many patients have put them on. It is unfortunate that the medical culture grooms doctors to assume that role. Is it any surprise that some doctors view themselves as special and above others? But it's lonely at the top, and when a doctor falls, such as when a serious medical error is made, it's a long way down. It's made longer by the fact that many doctors choose to suffer in silence.

While many physicians believe in the myth of perfection, they don't deal well with errors and find it difficult to put these errors into words. When doctors realize that they are part of a larger picture and imperfect or human like the rest of us, the doctor/patient relationship will improve, medicine will become more meaningful for both parties, and doctors will find that they can communicate more on the level of the patient without the fear of breaking the pedestal.

When doctors rehumanize themselves, medicine will gain, humanity will be helped, and patients will want to become more involved in improving their own health. Everyone will then gain.

Will Doctors Earn New Chronic Care Fee?

The Centers for Medicare & Medicaid Services (CMS) may think they are doing primary care physicians a good thing; however, only a few days after their announcement there is squabbling among the professional organizations and concern about making it easier to get the money. I think it is time to take them out behind the woodshed and give them the what for when they whine so much.

Shari Erickson, vice president of governmental and regulatory affairs at the American College of Physicians (ACP), wants to make it too easy for physicians to obtain the chronic care fee and do almost nothing to earn it. To me it sounds like she is saying they have it coming. This is not the intent and fees should be earned, Ms. Erickson. “Erickson said that the ACP prefers that official designation as a medical home does not become a prerequisite. That way, physicians who lack this designation still have a "nice pathway" toward payment models beyond traditional fee-for-service.” Bold is my emphasis.

“Jeffrey Cain, MD, president of the American Academy of Family Physicians (AAFP), said the new fee is part of the evolution toward a payment system that recognizes that "patient care requires more than face-to-face time."”

At least Dr. Cain accepts the “medical-home” status for earning the fee and clearly states that it should not be the sole criterion for earning the fee. He states, “The rationale for the proposed management fee jibes with the medical home.”

Both Erickson and Dr. Cain said their societies are still digesting the details of the CMS proposal. The proposed CMS regulations on the new fee are scheduled for official publication in the Federal Register on July 19. CMS will accept comments on them until September 6 and then issue a final version of the regulations on or near November 1. The proposed regulations explain how the public can submit comments.

The link above downloads a lengthy PDF file (over 580 pages) and reading is time consuming, but interesting.  I will be reading the publication in the Federal Register before making my own comments about the Chronic Care Fee.