Saturday, January 24, 2009

Using IT to change the Health Care System

The possibility of revolutionizing the Health Care System using information Technology is exciting, and I hope I live long enough to see it reach its full potential. I've blogged a lot about the concept of patients using the internet to help them take more control over their own health care. But, there are also provider-based technologies that will increasingly become available and also will improve the care system.

At eDoc, we've recently undertaken several project that, I hope, will be emulated or duplicated widely to improve the efficiency and quality and reduce the cost of health care. Briefly, these projects are:

1. Providing eDoc services to all Medicaid patients in the state of Arkansas (this project is slated to start in July of this year).
2. Providing a secure, online, web-based consultation portal for physicians in Arkansas to consult with a physician at the University of Arkansas about a problem patient.
3. Providing patients being discharged from the hospital with a card that gives them the URL to connect with physicians to ask questions about their hospitalization.
4. Providing a secure, web based portal for patients in the outpatient clinics at the university to contact the office and renew prescriptions, request appointments, receive lab results or ask clinical questions.

Broad use of these technologies thoughout the US will undoubtedly greatly reduce health care costs and improve patients' access to the health care system. By using online services like this, patients should never have to go into the office to see their doctor unless they have to have blood work, a physical exam, an imaging procedure, or some other procedure.

Viva the e patient revolution!!

Wednesday, January 14, 2009

Patient Advocacy During Hospitalization

I have had three recent family situations which have gotten me heated up on the issue of the need for patient advocacy. Its not that care without advocacy is necessarily bad. Its just that, as I reflect on it, I'm not sure it CAN be adequate without someone sitting by the patient who cares at a deep level--whether this person is a friend, spouse, family member, whatever--who is able and willing to constantly advocate for the patient.

Briefly, my "three situations" are: 1) a wife who has Waldenstrom's, post bone marrow transplant, who is returning for chemotherapy after three years treatment free; 2) a daughter who is pregnant (separated from husband), living with us, who is receiving obstetric care; and 3) a disabled son who is currently hospitalized in a small community hospital 2 hours away.

So, here's the dilemma: Each of these patients has varying needs and abilities to "fend for themselves" in the health care system. One of them is totally disabled and, thus, without someone present is totally at the mercy of the "nurse of the day". One day, he had a nurse who was caring and attentive and, the next day, he had someone who seemed to be totally over her head and, although she thought she was doing a good job, was doing a terrible job of taking care of the basics, monitoring output, attending to basic hygeine, etc.

So, I have been involved in a varied and fairly active advocacy role in each of these three situations and it is not an exagerration to say that none of them would have received optimal care without it.

What do advocates do and how does that impact the patients' care? Here is a brief list:
1. Assess the patient's physical comfort level and provide little necessities, body position adjustments, etc.
2. Double check all medications administered to make sure they are what has been ordered, in the right doses, and given at the right time.
3. Ask about key lab results and, if possible, keep copies and, if necessary, ask for interpretation from nurse or doctor.
4. Ask questions, questions, questions: is it time for the catheter to be taken out? If not, when? Is the IV leaking? When is discharge planned? What are the plans for discharge medications? When is the follow up appointment? And so on...

But, in spite of the importance of physical presence and asking questions, I am convinced that the mere presence of a "caregiver and advocate" changes the fundamental dynamics of a hospital care situation. It not so subtly gives a message that "we are watching what you are doing and will ask you if we have any questions or concerns about what is happening"?

It is not even fair to say that hospital caregivers intentionally neglect patients who don't have bedside advocates. I believe it is just that they are spread thin and stressed and, in many instances, need our help to meet the needs and priorities of the patient...

So, don't hesitate to serve as strong advocates for your hospitalized relatives!

Your comments and opinions are always welcome.

Friday, January 9, 2009

Are We Getting What we Pay For?

In today's Wall Street Journal, Deepak Chopra, MD and his colleagues wrote a very interesting opinion piece on the mainstreaming of alternative medicine. But I really thought the core message of the article was that, in the US, we are spending billions on health care, procedures, medication, and technology when much of what we are buying could be reversed with simple lifestyle change.

Instead of needing coronary stents or expensive cholesterol, diabetes or blood pressure medicine, patients really need to embrace smoking cessation, exercise, stress reduction, better nutrition, and having a more active and more supportive social life.

Physicians should be as excited about advocating healthy lifestyles (and providing guidance on how to do it) as they are in making complex diagnoses and prescribing procedures and medications.

Let me know what you think about this issue.

Monday, January 5, 2009

Are You Eating Your Way To Diabetes?

We all hear about the rapid increase in people with Type 2 Diabetes. The number of people with this disease in the U.S. has doubled in the last 20 years. If you do not have this type of diabetes, mostly caused by obesity, do not think you won't, especially if you are overweight or obese.

Theoretically, we could all have Type 2 Diabetes at a certain weight. As our fat cells, also called adipose cells, get bigger they release hormones that can trigger the high blood sugar of diabetes. Some people are more genetically prone to diabetes than others but anyone can get the disease if they stress the body with too much body fat. You could be eating your way to diabetes if your weight is going up.

How could you tell this? There are some early markers of developing diabetes. What is your fasting blood sugar? Diabetes is a level of 126 or higher. Levels of fasting blood sugar from 100 to 125 is called prediabetes, clearly on your way. Normal fasting blood sugars are between 60 and 90. Is yours closer to 90 than 60? Has your fasting sugar gone up since you gained weight. What about a sugar between 90 and 100? Many diabetes specialists think that any level above 90 should be considered prediabetes. I agree.

What happens to your blood sugar 1-2 hours after a meal? Above 200 is definitely diabetes. Above 140 is considered another type of prediabetes. Has yours gone up? You may not have diabetes yet, or even the official levels for prediabetes, but you may be on your way. Better to find that out before it is too late. The complications of cardiovascular blockage leading to heart disease begin before the blood levels reach the diabetic level.

Another thing to watch is your HDL (good) cholesterol. As your fat cells expand, the hormones released cause the HDL cholesterol to go down, which is not a good thing. The LDL (bad) cholesterol often goes up with weight gain as does the total cholesterol. If you have gained weight, you might recheck your lipid panel and see if it has changed from previously.

Realize that you too could get diabetes if your weight is going up. Maybe the scare of developing this disease is enough to motivate you to exercise, control your eating, and lose weight. You do not catch diabetes, you develop it. Find out if that is happening to you and do something about it if you are moving toward diabetes.

Friday, January 2, 2009

What Does it Mean for the Patient to be in Charge of their own Health Care?

Robert Veatch's book: Patient Heal Thyself: How the New Medicine puts the Patient in Charge is reviewed in the December 25th issue of the New England Journal of Medicine. Of two of Veatch’s main points, one is correct and one misses the point entirely. The first point: “Patients alone are in charge and have no choice but to assume this role” is correct and is essential to any patient's aspirations to stay healthy. After all, physicians' recommendations are worthless unless the patient understands, accepts, and follows them. So, if that doesn’t make the patient in charge, I don’t know what does! Any notion that the physician is "in charge" is more the physician's fantasy than anything else. A physicians role is not to be in charge of the patient's health, but to use their training and experience to guide the patient and to help coordinate their care and, in some cases, to directly provide some of that care.

Even more passive patients, who prefer to relegate decisions to the physician, are really still "in charge" in the sense that they are choosing not to question recommendations made or seek a second opinion. While it is true that many patients just don’t feel they have the resources or the information to do this, the internet has shifted the balance and now makes it possible to effectively and objectively research almost any medical question.

The second point, that “physicians will no longer be seen as capable of knowing what will benefit their patients” inappropriately relegates the role of the physician to a technician or an information resource. In truth the physician, by himself, has never been in a position to determine the best choice for the patient any more than a lawyer can determine what sentence a plea bargaining criminal can choose rather than going to court and taking a chance with the jury. The patient/client must do that.

But, there are a wide range of approaches that patients and clients use to arrive at decisions, whether they be health care, investing, legal, personal and otherwise. Wise ones inevitably choose their own course after appropriate due diligence. But there is a wide range of variability on how they go about this, from those who still prefer that their doctor make their decisions for them to those who simply want to do the research and have the doctor provide the support to proceed along their chosen course of action.

Most patients end up somewhere in the middle, whether that be in the office or through an online dialogue, and would like to at least hear the opinions of a trusted health care professional and use that information to help them make a decision. If someone is going through a painful divorce and needs legal help, does she prefer to go to the internet, pull up the relevant state law and tell her lawyer what to do? No! She prefers to tap his judgment and experience to make recommendations in response to which she makes a considered decision and moves ahead.

This is no different from the appropriate role of the physician: to enter a relationship with the patient, listen to their story, investigate their problem utilizing their training and experience, assisted by health care technology, then provide recommendations and then do it over and over again, many, many times, as often as the patient needs them to.

I believe the primary reason that this doesn't work as well as it should is because too many of us maintain the illusion that we are still in control of the patient's health and seem to think that status quo needs to be maintained.

So, what lessons does Mr. Veatch's book leave with us? In my opinion, it is a good wake up call for physicians. We need to embrace the "ePatient Revoution", recognize that the patient MUST be the one who is in control of their own health care, assist them in achieving this, and not be tempted to allow that to interfere with our professional self esteem because, in my view, it in no way threatens it!

Your comments and dissenting opinions are welcome.