Sunday, February 3, 2008
Lack of Primary Care Will Derail Reform
Health care reform is dead in the water unless we fix what is going on with primary care medicine in this country.Let's just play this out. We have about 47 million uninsured folks in the U.S. There aren't too many people who disagree with the need for universal coverage for all Americans. (How we pay for it is another topic... but expanding coverage is just good policy). At the same time as
Saturday, February 2, 2008
Seven Medical Myths
I love the British Medical Journal because it is filled with wit and just good interesting stuff. Those Brits know how to keep it real! The December issue addressed medical myths that we've all heard for so long that everyone believes they are true. They chose seven to research and found no evidence to support them:1. People should drink 8 glasses of water a day. They found that most people
Answer - Medical Quiz #5
The answer to the tongue lesion image below is #1- herpetic glositis. A severe herpes virus infection can inflame the entire oral cavity and cause multiple lesions on the tongue, lips and oral mucosa.
Friday, February 1, 2008
Medical Quiz 2008 - #5
Here we go again with another medical challenge. What is the diagnosis for this condition?Click on the image for a better view. The answer will be posted tomorrow. 1. Herpetic glossitis2. Apthous ulceration3. Pemphigoid4. Scurvy5. Oral candidiasis
Thursday, January 31, 2008
Cool Technology of the Week
When I was 18 years old, Sybex published my first book, "The Best of CP/M Software". That was followed by "Real World Unix", a roadmap to implementing Unix servers in small to medium size businesses, and "Espionage in the Silicon Valley", a collection of true stories about my experience working in high tech in the early 1980's.Each of these was published in the traditional way. I submitted proposals to publishers, received a small advance, wrote manically for months, reviewed galleys, and then thousands of first editions rolled off the presses. The process was time consuming, expensive, and involved many stakeholders.
The Cool Technology of the Week is LULU.COM, which completely revolutionizes the publishing process by supporting on demand publishing of any author at low cost. At CareGroup, we recently used Lulu to publish a book about the retirement of one of our longstanding employees.
Here's how it works:
1. Publish -You upload your manuscript and photos, then use their online formatting tools to specify the layout, size and binding. There are no set up fees - you just pay the cost of the book when you buy it, as you would in a bookstore. Lulu does not inventory any books, they are digitally produced on demand when ordered.
2. Sell - Lulu books are listed in the Lulu marketplace, but you can also get an ISBN number so the book will be available on Amazon.com, in retail stores, libraries and schools.
3. Connect - Lulu includes social networking tools to link together a community of digital media creators.
When I compare the process of on demand book publishing to the workflow I used 30 years ago, I'm amazed at how democratic publishing has become. Like blogging, anyone can become a published author with formal publisher. In fact, if I wanted to bind together my first 100 blog posts in book form, I could do so without a set up fee on Lulu, call the result something like "True Confessions of a CIO" and make it available on Amazon. This is my 80th blog post, maybe I'll do that after my 100th.
Wednesday, January 30, 2008
United Health hit with $3.5 million fine
United Health has been hit with a $3.5 million dollar fine by the Department of Managed Health and it couldn't happen to a more deserving company! The department of Insurance investigated the company and found it had violated more than 130,000 claims and improperly denied 30% of claims that were reviewed during the investigation. That is not an accident. Underpaying or denying 130,000 claims
Medication Reconciliation
One of the most challenging Joint Commission requirements for hospitals is supporting medication reconciliation workflow. This means that at every transition of care, providers must verify the medications that each patient is taking to ensure they are getting just the right dose of just the right medication. Why is this a challenge? Imagine that an 87 year old taking 14 cardiac medications visits an orthopedist for knee pain. The orthopedist must carefully record her current doses of Amiodarone, Lasix, Lipitor, and Zestril, examine her knee, prescribe medications, and document the visit, all within 12 minutes. For specialists, this may require a knowledge of medications they do not often prescribe and may take substantial effort if the patient has been referred from an outside provider and thus no medication history is available in the orthopedist's electronic health record.
To date, most hospitals and clinician offices have addressed this Joint Commission requirement by implementing paper processes. Very few vendors offer electronic solutions for medication reconciliation.
In July of 2007, BIDMC was visited by Joint Commission. We had been working on medication reconciliation workflow and software solutions for a year prior to this visit. During their visit, we were live with automated outpatient medication reconciliation, paper-based emergency department medication reconciliation, and paper-based inpatient medication reconciliation. The Joint Commission visitors were impressed with our software engineering but noted that we did not have 100% utilization of the software in our specialty clinics. We had 45 days to ensure 100% compliance, verified with an audit.
Over those 45 days, the Medical Executive Committee modified our clinical documentation policies to require medication reconciliation as part of retaining staff privileges. We assembled a multi-disciplinary committee to understand the workflow implications of medication reconciliation. We cleaned up historical medications by deleting all medications that had not been acted upon in three years. We temporarily hired 5 extra RNs to call patients at home and enter medication lists prior to their visits. When not calling patients, these RNs, who were located in our busiest clinics, cleaned up historical medication lists to ensure they were formatted properly for e-Prescribing renewals.
Our committee recommended hundreds of software changes to make the outpatient reconciliation process easier and we implemented all of them. Enhancements included the ability for any clinician in any clinic to quickly enter, update, or annotate (“patient is not taking as prescribed”) any medication, even if they were not the original prescriber. Of course all medication changes were documented in an audit trail. We enabled providers to enter patient self reported medications and we displayed an alert if the exact dose was unknown.
We modified our eprescribing systems to reflect community-wide medication history. This means that when a clinician writes for any medication, a history of every medication that has been dispensed at any US pharmacy appears and can be used as an aid to reconciliation.
We modified our emergency department clinical documentation system to support reconciliation of patient medications during ED evaluations and ensured all medications dispensed in the ED became part of the patient's active medication list.
On the inpatient side, we enabled discharge medications to be automatically converted to outpatient medications and made all discharge medication summaries available to every clinician. We are just finishing a completely automated inpatient medication reconciliation system which will enable physicians to verify all medications electronically while preparing the initial inpatient history and physical.
Our paper-based medication reconciliation processes will soon be retired.
The greatest challenge to implementing all these solutions was documenting the logical workflow required by clinicians, then getting the buy in of all the users of the system, given that it added substantial work to their day.
At this point, 5 months after our final joint commission audit, physicians are realizing the benefit of an up to date medication list and are saving time in the medication renewal process, receiving more accurate decision support when prescribing new medications, and have better documentation of patient compliance with their therapies. Patients are more satisfied as well, since they know all clinicians will use the same accurate medication list across our hospital and practices, making patient/provider communications about medications much easier.
It may have been one of our most challenging experiences, but in the end, all involved agree it was worth the pain.
To date, most hospitals and clinician offices have addressed this Joint Commission requirement by implementing paper processes. Very few vendors offer electronic solutions for medication reconciliation.
In July of 2007, BIDMC was visited by Joint Commission. We had been working on medication reconciliation workflow and software solutions for a year prior to this visit. During their visit, we were live with automated outpatient medication reconciliation, paper-based emergency department medication reconciliation, and paper-based inpatient medication reconciliation. The Joint Commission visitors were impressed with our software engineering but noted that we did not have 100% utilization of the software in our specialty clinics. We had 45 days to ensure 100% compliance, verified with an audit.
Over those 45 days, the Medical Executive Committee modified our clinical documentation policies to require medication reconciliation as part of retaining staff privileges. We assembled a multi-disciplinary committee to understand the workflow implications of medication reconciliation. We cleaned up historical medications by deleting all medications that had not been acted upon in three years. We temporarily hired 5 extra RNs to call patients at home and enter medication lists prior to their visits. When not calling patients, these RNs, who were located in our busiest clinics, cleaned up historical medication lists to ensure they were formatted properly for e-Prescribing renewals.
Our committee recommended hundreds of software changes to make the outpatient reconciliation process easier and we implemented all of them. Enhancements included the ability for any clinician in any clinic to quickly enter, update, or annotate (“patient is not taking as prescribed”) any medication, even if they were not the original prescriber. Of course all medication changes were documented in an audit trail. We enabled providers to enter patient self reported medications and we displayed an alert if the exact dose was unknown.
We modified our eprescribing systems to reflect community-wide medication history. This means that when a clinician writes for any medication, a history of every medication that has been dispensed at any US pharmacy appears and can be used as an aid to reconciliation.
We modified our emergency department clinical documentation system to support reconciliation of patient medications during ED evaluations and ensured all medications dispensed in the ED became part of the patient's active medication list.
On the inpatient side, we enabled discharge medications to be automatically converted to outpatient medications and made all discharge medication summaries available to every clinician. We are just finishing a completely automated inpatient medication reconciliation system which will enable physicians to verify all medications electronically while preparing the initial inpatient history and physical.
Our paper-based medication reconciliation processes will soon be retired.
The greatest challenge to implementing all these solutions was documenting the logical workflow required by clinicians, then getting the buy in of all the users of the system, given that it added substantial work to their day.
At this point, 5 months after our final joint commission audit, physicians are realizing the benefit of an up to date medication list and are saving time in the medication renewal process, receiving more accurate decision support when prescribing new medications, and have better documentation of patient compliance with their therapies. Patients are more satisfied as well, since they know all clinicians will use the same accurate medication list across our hospital and practices, making patient/provider communications about medications much easier.
It may have been one of our most challenging experiences, but in the end, all involved agree it was worth the pain.
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