AND Is a Front for Big Food Interests

Several tid-bits showed up on May 14 and May 15 in other blogs and need emphasis. The first I would like to point out is a blog by Jenny Ruhl here and the comment to it. The comment is technically in error as the ADA (formally the American Dietetic Association) is now AND (Academy of Nutrition and Dietetics). The URL given is still correct and does expose the companies they receive money from and then they promote these to us as dietitians. It is no wonder that the nation is becoming obese with this happening.  The graphic below is the one with Jenny's blog.

With my blog from May 22, 2013 and information from their own website, we are put on notice that the nutrition that they are saying we need protection from is the AND. Therefore, they want us to see the need the stricter laws giving them a nutritional advice monopoly to protect us from whom? That would be the Academy of Nutrition and Dietetics.

Next, I would like you to look at the following image. Then compare this to the list on the AND site. Five of the eleven corporate sponsors for AND show up on the Big Food list. This means Coca Cola, Kellogg's, Unilever, PepsiCo, and General Mills (big G) are common.

While there are some registered dietitians (RD) that are trust worthy, but for the most part, I will not consider the majority and especially those with the dual acronyms of RD and CDE. The junk carbs the AND promotes supply them with operating funds.

Patients Can Dream

I can dream, and they are not simple dreams. Medical care has become too complex and doctors are having less and less time to spend with patients. My ideal medical experience would be to have secure access from my home computer to my medical records on a server in the doctor's office. There I would be able to check my medical history for accuracy and possible errors. I would be able to add by date, health symptoms that I was feeling and maybe a scale for pain caused, or for queasiness not resulting in vomiting. The doctor would be able to review my entries on an as needed basis and send me an email to call or I could call the doctor if needed for an appointment or a televideo conference. When needed I could ask for a blood draw to check out a group of symptoms and the doctor would be able to approve or disapprove.

I would still have available regular appointments or on an as needed basis. When I would be at the doctor's office for an appointment, his assistant would pull up my records and check what may have happened to medications, symptoms since my last appointment and if, or if not, what could be the need for the appointment. Any additional, if any, information would be entered. When the doctor entered the exam room, he could check the screen for anything out of the usual and the results of any lab tests and be able to ask a few questions and if needed make a diagnosis and give me a prescription, if necessary, or discuss measures I could take to alleviate the problem.

Then if there was something that he could not diagnose or a test did not give an indication of a solution, he would be able to take the symptoms and any developed patterns to a connection to servers round the country and query for information and possible outcomes. If none were returned, then he could possibly know that there is no immediate problem. If there were a few similar instances, he could read what had transpired and decide if he wanted more detail. He could then query by the case (without personal information) and if there were enough similarity, he would have a phone number to contact and establish a dialog with the doctor involved to discuss the information. If there were other cases, then the doctor could talk individually with the other doctors or have a video conference with those that were similar to what he was seeing.

Then from what he learned he could do the tests indicated or if none was indicated, could still decide that more symptoms or pattern was needed. Then he would discuss with me what he had learned, instruct me of symptoms to watch for, what to do if they developed, or if a pattern developed and when to call. If any of these developed and he was confident enough he could then prescribe a medication, call me in for another test, or advise me to report to the hospital for observation, a treatment, or surgery.

This would be cost effective for me and my insurance, and time effective for him. Many tests could be avoided that would not have been productive in reaching a conclusion or diagnosis and would possibly clouded the true problem.

Some day, in hopefully the not too distant future, this will be possible. There may be patient monitoring applications available to monitor many symptoms and track certain information that may minimize office visits and allow treatments that are more accurate.

My main concern will be Medicare and insurance companies getting in the way and preventing this happening. Healthcare rationing and profit greed must be managed to make efficient use of the new technology. If these two items are allowed to run rampant, then technology may be of little value and often limited before they can be proven of value. With the current wave of limiting expenditure of resources, healthcare rationing may become a unwelcome necessity, but the current excessive profit motives of medical insurance companies can still be sidelined and kept out of most equations.

In my dream, I can see a great future for telemedicine and other technologies related to telemedicine. I can even see contract medicine gaining importance, allowing doctors to serve patients more effectively. This would be especially true in the rural areas and less doctor dense areas.

There are many other concerns that I have not touched upon, like the growing monopoly of hospitals. They too will become manageable and the loss of life now attributable to errors happening in these institutions will become manageable. Some day, and hopefully not too distant in the future. As telemedicine becomes more profitable and efficient, hospitals will need to become more efficient or risk going out of business.

Healthcare and Research Ethics Need Improvement P2

Part 1 of 2 parts

With the second article, the authors bring forward a new ethical framework for the integration of research with practice in what the Institute of Medicine (IOM) calls a learning healthcare system. “The framework includes seven obligations, six of which fall on health professionals and institutions, and the 7th on patients:

1. Respect the rights and dignity of patients
2. Respect the clinical judgment of clinicians
3. Provide optimal care to each patient
4. Avoid imposing nonclinical risks and burdens on patients
5. Address health inequalities among populations
6. Conduct continuous learning activities that improve the quality of clinical care and health care systems
7. Contribute to the common purpose of improving the quality and value of clinical care and health care systems”

The framework does incorporate both medical and research ethics and includes new obligations. The authors do acknowledge that the revised traditional concepts will affect the roles of healthcare providers and patients. The authors have tackled some long-standing problems with inequalities in health outcomes and in the evidence base for clinical decision-making. Among the examples of unfair inequalities the authors say should be addressed by obligation five is the scarcity of evidence for managing chronic illness in pregnant women, as compared to other adults with the same conditions. Women, and their children, would be well served by a healthcare system that continually learns from patient care.

The framework challenges previous thinking in research and clinical ethics. It calls for an ethical obligation on the part of clinicians, administrators, payors and purchasers to conduct research to improve health care quality and value, and on patients to contribute to such research. The authors write, "Just as health professionals and organizations have an obligation to learn, patients have an obligation to contribute to, participate in, and otherwise facilitate learning," that will improve the quality of the healthcare system. This is not a blanket obligation, regardless of risk. Some kinds of medical research, such as early testing of drugs still unapproved by the Food and Drug Administration, are not included and should always proceed only with the express, voluntary informed consent of the patient.

The patient obligation is to be focused on research that poses no additional risk beyond what patients face in clinical care. This would exclude research that compares different types of treatments, for example, surgery to medical management. The authors add that the framework includes obligations to avoid imposing nonclinical risks and burdens on patients, and to protect their rights and interests.

This may be the key when the authors say that extraordinary opportunities for learning are lost in our current system, because physicians and researchers face significant hurdles in capturing the rich information generated from thousands of daily medical encounters with patients due to overly burdensome oversight and consent rules. The new framework is intended to help reduce these hurdles.

The authors also state that they expect their articles will spark debate, and hope they will move the transformation to a learning healthcare system forward, both in its ethical underpinnings and in practice. They write, "We claim no more than a start on a subject that merits extensive investigation, and we welcome suggestions and commentary moving forward…We are in the early days of a progressive realization of a lofty aspirational goal, but given the preventable harm, waste, and uncertainty about clinical effectiveness in health care, efforts to accelerate learning should be given high priority."

My personal feeling is that the realignment of ethics is long overdue and with the increase in technology, much clinical research needs to be researched from the daily medical records of patients. This may be where valuable research can be gleaned.

Healthcare and Research Ethics Need Improvement P1

Part 1 of 2 parts

An article appearing in several sources on January 11, 2013 is the basis for what I am writing about. I have succeeded in acquiring the full text of the report and the editorials, but like the correspondent stated, it is very dense and packed with information. I am interested in the premise of thearticle and what effect it may have on diabetes and diabetes care. Redefining healthcare and research ethics could or should be applied to diabetes. What the American Diabetes Association and its related groups are doing for people with diabetes is more unethical than many people are willing to admit.

With the John Hopkins bioethicists making the call, this should have more weight behind this and in reading the information available to the public, this is a discussion with merit. As a patient, this is intriguing for me and sounds like something that needs doing. With the poor research the last few years that has not given clinicians any basis for changing procedures, this may be the avenue to greater innovation by the doctors in the trenches.

I believe that digitizing medical information is driving this change and this is good because maybe for once, we will not be chasing technology to get ahead in legal and ethical standards. This is needed for the medical field to help drive technology that is needed in so many ways. When a doctor is faced with something completely new to him/her, being able to query medical records from around the country and someday maybe around the world, may lead to a quicker diagnosis of something that is still in its infancy. A listing of symptoms and the ability to query medical data bases may lead to teleconferences with two or more doctors that have experienced this before and this ability may enhance diagnosis and result in earlier treatment which is often needed.

I am fascinated that the procedures presently used for medical research are being challenged and with justification. In selecting study participants, most often the patients think they are being treated when in fact they are the ones on placebos and do not receive any benefits from the study. Yes, some are receiving treatments, but not necessarily the correct amount of treatment. “The authors challenge the assumption that participation in clinical research by definition offers patients less potential benefits and puts them at greater overall risk than clinical practice, as well as the assumption that research imposes more irrelevant burdens on patients.”

In the current healthcare system, over 50 percent of medical treatments are used without sufficient proof of effectiveness, leading to 100,000 deaths annually from healthcare acquired infections. This means that the labels of “research” and “practice” are terms that should be our central moral concerns and no longer serve as effective guidelines for what requires ethical scrutiny.

For clarity, I am quoting two paragraphs, "Far too often, doctors do their best but simply don't have the information to tell them which approaches or treatments work best, and patients are suffering for that lack of knowledge," says Nancy E. Kass, deputy director for public health at the Johns Hopkins Berman Institute of Bioethics, and lead author of the article. "We're finding that patients are both underprotected from risks in medical treatment and over-protected from low-risk quality-improvement research, bringing progress to a dangerous stalemate that is costing lives," the authors write.

Instead, the authors say that healthcare should be moving toward a system in which clinical research and clinical practice are integrated, and every clinical encounter is simultaneously an opportunity to provide needed care to patients and also to learn from that to improve the care provided to future patients.”

This is great and needs to be put into practice. I do have to question how they will be able to get all doctors on board. There are just too many doctors that think they are all the patient needs and are more interested in the afternoon golf game or what race is being run at the local track. Will they take the time to rethink and relearn their profession if they are put center stage when clinical research and clinical practice are integrated? For some reason, I don't see this happening for these doctors. They want others doing all the research and handing it to them to put in practice or showing them how it works in practice. They have little interest in research unless it makes them into more all-knowing people than they perceive they already are.

Then on the other side, there will be doctors that will welcome research/practice integration to be able to continue to defraud their patients and payers, and hide it in the name of research. As much as I may dislike the previous doctors, these doctors are the “rotten apples” of the medical profession and very difficult to put out of the profession.

One of these research/clinical integrations developed for a doctor and she covers what has happened to her idea to date. While it may not fit what most would be thinking, this is what many doctors do not realize and are afraid to speak out about. This problem is selecting a suitable antibiotic for empiric treatment of UTI (urinary track infections) and knowing what the local clinicians are finding for drug resistance preventing rapid clearing. Does this doctor have this information yet – no, but it sounds hopeful that it may be forthcoming in the future.

This doctor was correct in her thinking that this information should be available to clinicians and that it was not necessary to use patients names, but just the statistics of what antibiotics were having problems clearing UTI in the area she was located. Some UTI strains are more resistant than others to certain antibiotics. I applaud this doctor for thinking outside the box and attempting to help a patient by discovering which antibiotics were not as efficient with the current strain of UTI.

Statins Receive a Lot of Fuss – Justified?

Where some writers get their headlines, I am still trying to comprehend. This writer in Present eLearning states as her title “Should Statins Be in the Water?” has me very concerned and wondering why this could even be considered. For years, we have been taught that fluoride was necessary in our drinking water. Now that trend is slowly disappearing and more research is discovering some of the side effects of this that are not so healthy.

With statins and their side effects, I would fight this to the bitter end if I thought this writer was serious. We simply cannot allow this to happen, as our children do not need statins. One issue alone should stop this from happening and that would be if they included the wrong statins in our drinking water as this could exponentially increase the number of people developing type 2 diabetes. And we think we have an epidemic now. Certain fruits (grapefruit and its relatives) would need to be banned because of their potential deadly side effects when consumed by people on statins. See my blog here.

So when writers allow something like titles to be part of any discussion, they need to be called out about this. I have been carefully watching and since the publishing of this on March 12, 2013 and to-date have seen no one disputing this. Did Joy Pape, RN, BSN, CDE, WOCN, CFCN, PRESENT Diabetes, and Contributing Nursing Editor, really think that the title would go unnoticed?

Telemedicine Is Gaining Support - Part 2

Part 2 of 2 parts

Some important history needs to be part of this blog. “The University of Kansas Center for Telemedicine & Telehealth is a recognized world leader in telehealth services and research.” I would not have included this if I did not believe it. I have a distant relative that has been a recipient of this service and he says it was needed and he was thankful it was available when he needed it.

“Beginning in 1991 with a single connection to a community in western Kansas, the Kansas telehealth network now has accessed more than 100 sites throughout the state, has conducted many thousands of clinical consultations for the people of Kansas and has hosted hundreds of educational events for health professionals, teachers, students and the public.”

This is not the total of universities, but none has had the success that U of K has had or the range of population across the state. Other universities are modeling after the University of Kansas and are still developing especially when not blocked by state medical boards.

The benefits of telemedicine in states that are largely rural are more evident than in states that have some large population areas. Rural physicians and clinics can,

• Receive education from the specialist/provider
• Better health outcome for their patients
• Enhanced community confidence in local healthcare
• Attend continuing medical education courses from their clinic

Patients benefit,

• Loved ones remain in their community with family support
• Cost savings from not having to travel extensively
• Immediate urgent care
• Confidentiality of specialty examination or visit (Because the patient visits the general practice doctor, he can be seen for any specialty care without anyone else knowing)
• Patient education courses (nutrition, oncology, etc.)
• Properly stabilize patient prior to transport
• Early Diagnosis prior to escalated medical episode

Rural Patient's Community benefits because,

• Dollars follow the patient
  • Patients that routinely travel to visit doctors in large urban areas tend to purchase their goods and services from those cities,
  • Telemedicine keeps those dollars local.

Telemedicine Providers (hub sites) benefit by,

• Expand patient outreach
• Major surgical procedures resulting from the initial telemedicine consultation
• Reduction in ER visits
• Promotion of Hospital
• Charge tuition for clinician education courses (CME, CNE, etc.)

• How can we give any hospital or clinic immediate access to a vast amount of medical experts, healthcare education/information, and support from other physicians.

These benefits can become powerful benefits for telemedicine in states like Kansas, Montana, Wyoming, and other states. Physicians with access to telemedicine will be more likely to remain in these largely rural states. Residents will be happier not needing to travel for hours to be treated and will welcome and utilize nearby physicians.

Telemedicine Is Gaining Support – Part 1

Part 1 of 2 parts

I know that there are a lot of definitions available to apply to telemedicine. Telemedicine in one form or another has been around for about 50 plus years. Most of telemedicine pre 1990 was by use of telephone or occasionally when publicity could be had, some TV stations would lend their facilities to aid in telemedicine.

Then in 1991, the scene started to change. Computers became the medium for telemedicine. Today there are mobile devices and portable tablets being used for telemedicine. Terminology is expanding and more terms are gaining acceptance. Sometimes even I need to wonder which term(s) to use.

Almost 100 percent of telemedicine today uses telecommunications. We have the term telehealth, mHealth, eHealth, and health information technology (HIT). This is not a complete list as there is others gaining acceptance such as RPM for remote patient monitoring.

A concise and yet simplistic definition is, “Telemedicine is the ability to provide interactive healthcare utilizing modern technology and telecommunications.” I have encountered this usage from several sources and therefore do not know whom the source of the original use should be credited. This is also revealing in that telemedicine is not a separate medical specialty. Many specialists make use of telemedicine and think nothing of it.

Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care. Even in the reimbursement fee structure, there is usually no distinction made between services provided on site and those provided through telemedicine and often no separate coding required for billing of remote services. However, some state medical boards are lobbying for a different set of billing codes to differentiate and control groups using telemedicine.

Some attempts are being made throttle telemedicine and force patients into a doctor's office, or a hospital and eliminate telemedicine. I hope state legislatures will reverse this to allow telemedicine to expand in not only heavily populated areas, but also especially in largely rural areas where patients would need to travel several hours to see a doctor or have access to a hospital. Some federal programs have stepped into very remote areas to lend assistance to telemedicine.