Docnotes

What makes a good doctor = what makes a good plumber.

Medical Decisions are hard to make.  Even when they seem easy.  

I'd say that the TV show "House" is popular because Dr House seems to focus on giving patients what they need (honesty, transparency, certain treatments) and not necessarily what they want.   In his case - the difference between the two are entertaining.   Does that make him a good doctor? 

In real life - this is much harder.   There's ample evidence that physicians' decisions are based on many factors.  What's best for the patient is simply one of these factors. 

We've had a medical student working on our office recently - and it's been interesting to see my practice style mirrored in her eyes:

• I "actually listen" to my patients (who doesn't?   I wonder ...)
• I spend lots of time with my patients (no wonder I come home late every day!)
• I hear what they mean - not just what they say (the hardest part)

I re-told this story to her - in abbreviated form.  I posted it nearly 5 years ago - but the principles I tried to highlight then remain important yet under-represented on the Internet today.  Medical blogs are now far greater in quantity - yet I still think there are rather few of them  that express the transparency that the initial work a few of us were striving for back then.   There are so many competing interests - for our time, our money, and our attention.  Without good principles - I'd argue that there is no way for physicians to stay the course - and really make the best decisions for our patients.

The National Physicians Alliance is a relatively new organization that's building steam - based on good principles.  It's great to see an organization that is committed to "Advancing the core values of the medical profession: Service, Integrity, and Advocacy."   You can also read the NPA’s ISSUE BRIEF outlining reasons why physician prescribing data should not be made readily available to pharmaceutical companies.  The issue brief mentions describes how to opt out of pharmaceutical industry data gathering by enrolling in the AMA's Physician Data Restriction Program (PDRP).  Cool.  Check.  Done. 

Integrity is so important - yet so often suspect when there is opacity.  Exposing our patients to the uncertainties of our profession is a cornerstone of shared decision making - yet it takes so much more effort - and so much more time - I'm not surprised that so few physicians actually do it. 

The same goes for plumbers.  We had a "free" cleaning of our furnace performed by these folks last week.  The service rep called my wife at work and told her we needed a new humidifier element for $45.  He happened to have one.  Said OK.  We also needed a new solenoid for the humidifier for $89 "on order."   Turns out - I replaced the humidifier element about 6 months ago (should be done once/year) and the solenoid seems to work just fine to me.  You can listen to  his explanation - left on our voicemail.   Now -  look at the picture. Water running pretty well, if you ask me!   I filled an 18 ounce cup in under 30 seconds.  If that's a "very small amount of water" - I think Gary needs to go back to plumbing school.

Either Gary is stupid - or he's lying.  Either way - I can't trust him or his company ever again - as I suspect that he's got his interests above mine.  I could buy the solenoid (see link above) for $45 if I really needed one.  And I'm a little mad that he took my 6 month old humidifier element with him when he sold me the new one (it's the honeycomb thing in the picture).  Either way - he can't be trusted.

We need trustworthy plumbers, doctors, bankers, lawyers, software developers, etc.    The principles of the profession  must guide our decisions.  If not - we will always be distracted or seduced by the many other choices on our path.  Plumbers who invent problems, doctors who self-refer, and software developers focus more on the icing than the cake - all compromise their integrity in the same way - and will ultimately lose.   

Physician's First Watch Reviwed

Today Enoch reviews PFW. As usual, Enoch "gets it."

I've been involved with the project for a long time - and it has been a privilege to be involved in something so substantive.

In some ways - PFW serves one of the original goals that medical blogs were trying to reach: reviews of (and pointers to) important medical news on a regular basis. The "regular basis" is an important differentiator between weblogs and a professional he developed and provided resource such as PFW. There is no expectation that a blogger make a post every single day. On the other hand, a product such as PFW fields a reputation as a reliable new source by providing news and information on a daily basis.

Sometimes this is a true challenge, since there have been days in which there is clearly a dearth of truly important medical news.

It's interesting to see that medications gape has discovered and increased logs in the past 6 or 12 months. I remember when Steve Hoffman was there and Steve single-handedly motivated the company to provide RSS feeds well before most people knew what RSS feeds were. It even 18 months ago, it was hard to get Netscape to understand how powerful weblogs could be as a way to build and maintain readership.

And this is why PFW still differs quite a bit from weblogs: We provide important medical information in it claim, concise, well written summary that is deliver daily via e-mail or RSS. There is (by design) very little editorial opinion expressed about the content. In a conversation about the project with the neck a few months ago when I was in San Francisco, and when he pointed out that the discussion around the content may be just as informative or important for readers. He maybe right, but there is no reason that PFW can't serve as the nidus of such a discussion that takes place elsewhere.

For example, this story about salmeterol reminds us of the dangers of this long acting beta agonist when used incorrectly. I'm still not convinced that salmeterol is a dangerous drug inherently. salmeterol (like any medication) should be used carefully and appropriately. From my perspective, the article (and the previous warnings about salmeterol) or more about asthma than this medication. Asthma is a very serious illness and we need to understand that beta agonists (either short-acting or long acting) only treat the symptoms of this disease. Just as no one would expect albuterol two "cure" asthma, salmeterol plays no role in reducing inflammation as would corticosteroids or theophylline.

The staff editors and physician editorial board members of PFW discuss (by conference call) each article twice before publication. These conversations are often robust and educational for all involved, and sometimes I wish that the readership had access to some of the content of our discussions.

Yet if we remain focused on our goal of providing concise, well written summaries, perhaps the medical "blogosphere" will serve the function of creating and maintaining a forum for discussion of these important topics.

 

The EHR consolidation begins ..

CCHIT released the results of the first round of EHR certifications. Products that don't have certification will fall out of the marketplace. Yeh ... you can disagree .. and whine about CCHIT being a tax .. and how small vendors can't afford to do the certification .. but the certification is necessary and important. It does level the playing field a bit ...

Allscripts (HealthMatics Electronic Health Record 2006) Allscripts (TouchWorks Electronic Health Record 10.1.1) Cerner Corporation (PowerChart 2005.02) Companion Technologies (Companion EMR v8.5) eClinicalWorks (eClinicalWorks Version 7.0 Release 2) Emdeon Practice Services (Intergy® EHR v3.00) e-MDs (e-MDs Solution Series 6.1) Epic Systems (EpicCare Ambulatory EMR Spring 2006) GE Healthcare (Centricity® EMR 2005 Version 6.0)

JMJ Technologies (EncounterPRO® EHR 5.0) McKesson (Horizon Ambulatory Care Version 9.4) MCS-Medical Communication Systems (mMD.Net EHR 9.0.9) MedcomSoft (Record 2006 (V 3.0)) Medical Informatics Engineering(WebChart 4.23) Misys Healthcare Systems (Misys EMR 8.0) NextGen Healthcare Information Systems (NextGen EMR 5.3) Nightingale Informatix Corporation (myNightingale Physician Workstation 5.1) Practice Partner (Patient Records 9)

EHR != redunction in health care costs

It Ain't Necessarily So: The Electronic Health Record And The Unlikely Prospect Of Reducing Health Care Costs -- Sidorov 25 (4): 1079 -- Health Affairs

This article has been widely cited in the last week or so. It's a good read. Not sure I agree entirely .. but there are some valid points.

... and Matt points us to this excellent summary (pdf) on IT tools for chronic disease management.

Wiki for the Intranet in healthcare

See this post on using wikis for an Intranet in healthcare.  Wiki software is getting good enough these days that the look-and-feel is now tolerable for an Intranet.

Many years ago (1999) .. in a galaxy far, far away .. I built an Intranet home page that was butt-ugly, but it got the job done, and I was trying to spread the concept of an Intranet as a useful tool for clinical and administrative tasks.

Alas, that page still adorns the Intranet there (though it doesn't run from a server under my desk anymore, thankfully!) and while progress is being made (the www site was recently revised - though usability experts would likely give it a C+ at best) .. while I have moved on to other places.

 .. and one of the most successful projects at CapitalCare was the re-building of the Intranet as a Wiki.  It was fun and challenging and I can take credit for only planting the seed and evangelizing a bit.  Watering, fertilizing and nurturing were well managed by a great team of colleagues. 

Physician's First Watch

Physicians' First Watch launched today

What's good about PFW:

• Daily updates on important medical publications and news
• Professionally written, concise summaries
• Hyperlinks to relevant information and source article (see dave's post on how "sending them away" is a fundamental law of making money on the Internet)
• Stories are thoughtfully reviewed by a team of physician editors yeh .. I'm of of 'em
  
• Editorial selection of articles or news items for inclusion is unbiased - without any influence from advertisers, mafia bosses, or old college roomates
  
• Available for free, in the flavor you prefer: RSS or e-mail

I'm hoping Enoch will chime in about what's not-so-good about PFW.  I know he has some concerns -- and perhaps some suggestions for improvement ;-)

On the Medlogs Controversy ...

Looks like there is a bit of a spat between an anonymous reader and Eliot Gelwan.

Weblogs on Medlogs.com are selected.  Sure .. some are NOT selected for inclusion .. and there are many reasons for that .. one of which is that I don't have the time to review all of the new submissions (I'm about 200 behind at the moment!). I take the editing functions seriously .. though I yearn for a better method of categorizing the blog than the one we devised years ago. I have resisted commercializing the site - at the expense of revenue - so we will all have to wait for medlogs 3.0. But I digress .. The others reasons I don't include a blog in medlogs:

• I don't think that the blog is about issues relevant to healthcare
• The blog promotes a business rather than discussion

Not much else. I would argue that politics is often (always?) relevant to healthcare, and that separating science from politics is more of a challenge than most of us will ever admit. The whole point of weblogs is to learn from each other. If you disagree with someone - well then that is great. Disagree and make your point well so that we can all learn from the discussion.

RHIOs: The Next Big Thing?

I've done a lot of reading this weekend about RHIOs.  RHIOs are Regional Health Infromation Organizations.

There are a number of reasons I've been doing my homework on this - and a primary one is that our region may have some opportunities to begin some collaborative work, and I think it's important that I understand as much as I can about some of the issues involved.   I've done some of this homework before - but there has been quite a bit written about this recently - so it was time to catch up.

Here's a short tour of some of the reading.  Let's start with some of the most recent information .. which is the transcript ( and video!) of the ONCHIT's most recent meeting:  November 29, 2005

Be sure to read the transcript.  It's very interesting .. and reveals some of the vision of the future of HIT.  Doug Henley shares an important point:

…about demographic data of a patient, registration data, and they walk into a hospital physician’s office and they want to rather than fill out the clipboard three different times, they say “my data is available on www dot whatever” or it may be on a memory stick and “here I give it to you or give you access to it”. So to reinforce my comments earlier about integration or interoperability, it is one thing to have the patient in this case in control of that information, which is great for updating purposes etc, but most places in the system now – forget the HRs for moment – have for want of a better word practice management systems in their electronic. What we don’t want to have happen is for that patient to show up with a memory stick with that data or a Web site and somebody to have to go to it and re-key it and re-enter that information. It has to be able to flow into other systems freely, interoperably, so that hands don’t have to touch it any more in terms of mistakes that could be made. That could be an EHR, it could be allergy information, it could be medication information, and we don’t want mistakes to be made so wherever the data is, it has to integrate across various sites of service and flow freely from point A to point B to point C."

Of course, this is self-evident.  But it's important that he says this - and that there seems to be concensus that this is what the government wants - and that the government will help to faciliate this vision. 

.. And here's an interesting little article on RHIO resistance.  CIOs - generally a cautious species - are not uniformly embracing RHIOs.

.. Ignacio Valdez recently wrote a rather thorough editorial on the topic:

 

"Does it bother anyone that for years, Health Information Technology (IT) successes implied by the news and even in casual conversation may largely be an illusion?"

 

I  don't always agree with him - but this time, Ignacio is right on target.  He points us to this old paper by Paul Starr:

Smart technology, stunted policy: developing health information networks -- Starr 16 (3): 91 -- Health Affairs

But some RHIOs are working well .. right?

Here's one physician's view of a RHIO that's in our backyard  - 50 miles South of Albany.

And of course the Massachusetts project has been quite successful.

So how can we make sure that our local efforts are successful?

Ther is ample guidance from the RHIOFederation -  which is a product of HIMSS

Nancy Lorenzi's excellent 2003 essay on strategies for creating successful local health information interface initiatives (LHII) .. reflects on some of the rare successful implementations in the last decade.  Some key points:

1. Building an LHII is more of a political process than a technology process.
2. Collaboration is achieved through consensus built on sharing and trust.
3. The LHII must be structured so that participation does not mean the loss of
power, control and/or status.
4. Being the champion for an LHII requires risk-taking behavior.
5. Participant acceptance comes in phases and requires knowledge of the
participants needs.
6. Creating an LHII will take time, both in the initial work and for the length of
time until it is the “new” way of working.

Beginning with some shared principles would be a good first step.  Without clear principles - any project is a rudderless ship. 

What might be some of these beginning principles?  

• The RHIO will enhance the quality and efficiency of patient care
• The RHIO will provide adequate security to protect against inappropriate access to PHI
• The RHIO will be managed and coordinated transparently - so that trust and collaboration is fostered.
  

Hmm .. I've worked on this for a while .. time to post .. but I expect I'll add more to this.  Please use comments to make suggestions for changes or enhancements.

Medical Blogs etc.

Dave Winer linked to yesterday's Grand Rounds post and the server is taking a big hit today.  I reorganized the archive template to load a bit faster .. and provide more context.

Doing the Grand Rounds reminded me that bloogers like (love?) traffic.   Do lots of hits define a good blog?   I remember Steve talking at the first Bloggercon about watching his traffic logs and keeping an eye on the referrers - always interested in who is out there reading what he writes.

I'm getting lots of e-mail this morning about posts that I didn't include, or suggestions for more.  No - these aren't the online Vi_g_a (dare I even write the word for fear of attracting TrackBackSpam) sites - but real bloggers who just want their message "out there."

Contrast this with the bloggers like Kevin and Sydney and DB.  Bloggin away .. and doing great work - whether you read it or not.  My best posts are written for me - not for you. 

I'm not saying that wanting traffic is bad (yeh - I sent Dave an e-mail inviting him to post a link) but I don't think that it should be the primary reason for doing this sort of writing.  

Grand Rounds #53 Published

Here is Grand Rounds for the week of September 26th, 2005.  It's the 1-year anniversary of Grand Rounds - and I want to thank Nick for setting up and coordinating this weekly review of medical weblogs.  Grand Rounds has grown enormously over the past year .. and augments our medical weblog aggregator (medlogs.com) quite well. Here's an archive of all of the previous Grand Rounds editions.</intro>

Nick thoughtfully asked me to host this week's edition - even though I've not been as active with posting for the past 6 months or so.  He thought I was the first medical blogger - but in fact, that was David Theige who hosted MedEdNews beginning in 1998.  My blog - Family Medicine Notes - was started in earnest in early 1999 - but the current site has archives going back to November of 1999.

Grand Rounds this week will be a bit of a history of medical weblogging - with appropriate (I hope)  mention of some of the current issues and recent posts of interest.