Monday, October 29, 2012

Getting Used to Electronic Health Record

From this...
To this

I will start with full disclosure.  I still use paper charts.  While I think my practice of medicine is "uber"-up-to-date...the truth is it could be 1950 when you look at my patient records.  Charts are huge and some  patients I've seen for decades are on volume 3, just to make them manageable.  So this very week I am coming on board with a full blown, state-of-the-art Electronic Health Record.

The government is pushing EHRs and, in fact CMS (Center for Medicare and Medicaid Services) has already imposed a 1% penalty on  doctors  that are  not doing e-prescribing of prescriptions.   The penalty goes up to 1.5% in 2013.  There are also some large incentive dollars connected with "Meaningful Use".  It is a complicated set of criteria put out by CMS that pushes physicians toward investing in the EHR.

With all of these incentives why haven't more physicians converted?  For one it is darn expensive and the best systems require large groups or hospital funding to make it financially feasible.  Staff needs to be trained, equipment purchased, software and licenses purchased,  Internet technology (IT) support is needed and the doctor's productivity and ability to see the same number of patients declines. And it totally changes how you and your staff do your work. 

The advantages are numerous, however.  Having access to instant, legible information all in one place, shared by all of the caregivers is huge.   The EHR gives easy access to consultant notes and all tests.  When I am on call at night or weekends I can see my patient's information and it will prevent medical errors.  The EHR can be programed to give "alerts" for drug reactions, needed screening tests and medical information.

So it is a no brainer that we all need to switch to the 21st century and start using technology to help us deliver better care.

I have already gone through an entire day of training and will be using more of my "free" time this week to abstract my old charts, learn the system and develop my own practice templates in the new EHR.  I will need "at my side" IT support when I first start using it with patients.  I think my patients will understand if it is clumsy at first.  And they will surely like the ability to see their own lab tests and make office appointments on-line.

I am looking forward to the change but also wary of what is ahead.  Internal Medicine is already a grinding specialty with low pay and long hours.  Spending more hours with an EHR is not appealing but I hope the benefit to patients and safety makes it worth it in the long run.

The graph below is on a scale of 1-5.  1=poor, 3=neutral and 5=excellent.  You can see that none of the EHRs scored very high with the Physician users.

                           Satisfaction with EHRs by Employed Internists in large Practices

Criterion Rating Averagea
Easy to learn 3.62
Ease of data entry 3.57
Overall ease of use (intuitive) 3.45
Ease of EHR implementation 3.43
Reliability 3.99
Adequacy of vendor training program 3.55
Vendor continuing customer service 3.63
Interactivity with other office systems 3.29
Value for the money 3.46
Physician overall satisfaction 3.51
Staff overall satisfaction 3.55
Appearance/overall usefulness of the end product (eg, notes, consultations) 3.68

Wednesday, October 17, 2012


The answer to yesterday's medical challenge was #1 angioedema.  The patient had progressive swelling on the face and had previously had swelling of the larynx, trunk and extremities.  A diagnosis of hereditary angioedema was made from a blood test.

Angioedema just means swelling under the skin.  Spots of angioedema are called "hives" and they are usually from an allergic reaction.  Histamines and other chemicals are released by certain types of white blood cells when an allergen is detected.  This can occur because of insect bites, animal dander, pollen, food allergies, and certain medications.  People with hereditary angioedema, a rare condition,  lack a certain protein (C-1 esterase)  that is part of the body's immune system.  The swelling can come on quickly and be dangerous if it limits breathing through the larynx.

For more common hives (urticaria) or angioedema, antihistamines are the best treatment and avoidance of the allergen.

Thanks for your diagnoses.  

Monday, October 15, 2012

EverythingHealth Diagnostic Challenge

Hello Readers,
This weeks Image Challenge from The New England Journal of Medicine is a good one.  Also it is pretty common.  The patients symptoms developed over a few hours and she came to the Emergency Room.  Is it:

1.  Angioedema
2.  Facial palsy
3.  Frey's syndrome
4.  Parotid adenoma
5.  Parotitis

 Make your best diagnosis in the comments section and the answer will be posted tomorrow.

Saturday, October 13, 2012

Fallen Hero-Lance Armstrong

Reading the daily updates about the Lance Armstrong bicycle team doping scandal is like watching a train crash.  It gets worse and worse and there is no turning back for America's sport hero, Lance.  I read his book "It's All About the Bike" and even wrote a book review on it, praising his true grit story and come-back from being on death's door from testicular cancer.  Lance Armstrong, the boy next store with his good looks, amazing athleticism and cancer charity (Livestrong) has fallen off his pedestal.

The reports that are now being disclosed by his bike team aide, Emma O'Reilly  show that Lance and his team ingested and injected a boatload of illegal substances to improve performance over their entire successful careers.   The one that caught my eye was injectible testosterone, a performance enhancing drug when used in high quantity.  I thought back to his diagnosis of testicular cancer and the rapid spread of the disease before he was even diagnosed.

Testicular cancer is highly curable when caught before it spreads.  There are different types of testicular cancer but the most common originates in the germ cell, which are the cells of the testicle or gonads.  These are the cells that produce sperm and are also triggered by the male hormone testosterone.

Could the testosterone he injected along with other performance enhancing drugs have contributed to his cancer?  I've not seen this analyzed yet in the medical literature but it should be an obvious question.

There are no easy answers to this because testicular cancer is a rare disease of young men between the ages of 20-39 years. Young men do not ordinarily encounter exogenous testosterone (translated: young men do not get testosterone from outside their own body production).  But Lance Armstrong used large quantities of testosterone to boost performance.  Since testosterone has its effect on these very cells that turned into malignancy, the question must be asked.

Mr. Armstrong continues to deny his involvement in doping but he has accepted the life-long ban from biking and the stripping of his tour de france titles.   We all love heroes and watching them fall is both sad and disappointing.

Wednesday, October 10, 2012

Different Roles in Health Care

I was working late this week; making patient call backs, filling prescriptions, reviewing labs and finishing charts from the day.  It was dark out and the medical office was quiet and empty.  The janitorial crew started their work of emptying trash, picking up the scattered debris from the busy patient flow and sanitizing surfaces.  I looked up and a beautiful Latin woman, age about 30,  wearing latex gloves, was emptying the overflowing trash can.

"You are working overtime", she said with a heavy Hispanic accent.  I laughed, realizing how late it was and how tired I was and still had more work to do.  Then I stopped and really looked at her.  She was busy putting liners in cans and dusting surfaces.  She was working fast because there were many other offices ahead of her that also needed cleaning.

"You are working overtime too", I said.  "Yes", she replied, "I will work until 12:30"  (that's AM)

"I bet this is a second job for you", I guessed, and she replied "Si, I will go to my job at the food court in the morning".

"Thank you for what you do here", I said.  "Without the work you do at night we could not take care of our patients.  Coming to work and seeing everything so spotless lets us take care of people so I thank you."

I have thought about this short interpersonal connection many times and how important it is to stop and really look at another person.  I had been feeling "put-upon" with my workload, which was nothing compared to the work this young woman had in front of her.  In our society a minimum wage job is not enough to live.  People need two back to back jobs to survive.  Yet she was working with grace and dignity and without complaint.  In fact she was noticing that I was there late.  Amazing!

Taking the time to realize that others are facing challenges in their lives and learning from the grace they bring to life is an important touchstone for grounding us in our work.

Monday, October 1, 2012

Knee Replacements on the Rise

According to a new study in JAMA, knee replacement surgery could reach 3.5 million a year by 2030 in the United States.  Wonder why health costs are rising?  We have new expensive technology that improves quality of life but may also break the Medicare bank!

The study showed that the number of knee surgeries performed more than doubled from 1991 to 2010.  Fortunately, length of stay in the hospital (a major driver of cost) decreased from 7.9 days to 3.5 days.  In the 90's more patients were discharged to institutions for  rehab and now patients are discharged to home with home health services.

The researchers attribute the potential increase in demand to aging baby boomers and a rise in conditions that contribute to arthritis - namely obesity.  Also there are more trained orthopedic surgeons that perform the surgery and it is becoming more mainstream.

Total knee replacement (TKR) will be a key driver of health care costs in the future.  Many studies have demonstrated that TKR is cost-effective because it improves patients' activity and health-related quality of life.

The total cost for TKR in the United States (including hospital, pre-op tests, medical supplies, OR fee, Xrays and physician fees) runs between $35K - $60K.  For best results, patients should find a surgeon that specializes in TKR and runs a "focus factory" with strict protocols and a comprehensive treatment team for quick ambulation and rehabilitation.
My own TKR

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