Navigating Healthcare – Patient Safety and Personal Healthcare Management

#VoiceoftheDoctor – This Months Guests – Brian Phelps, Karen Kirby and Kathy Douglas #NursesWeek

Posted in Uncategorized by drnic on April 30, 2012
Join me this month with the following guests

May 4
I will be joined by
Brian Phelps, MD
We will be discussing Best Practices: for Developing Apps for the Medical Community including the integration of speech
Montrue technologies were the 2012 Mobile Clinician Voice Challenge Winner with thier award winning SparrowEDIS

May 11
May 6 – 12 is National Nurses week
In honor of this I will be talking with Karen Kirby, RN, MSN, NEA-BC, FACHE who has over 25 years of experience in healthcare administration and has held top-level nursing and hospital administration positions, and serves as an Associate at the Institute for Nursing Healthcare Leadership within Boston’s Harvard healthcare community.

We will be joined by Kathy Douglas, RN, MHA, who is the President & CEO of the Sedona group and has just completed a Documentary Feature Film “Wise Women of Sedona“. We will be talking about nurses and their impact in the healthcare system, the rise of the Chief Nursing Information Officer (CNIO) and the current project they are both working on Nurses the Movie:
An in-depth exploration of the complexity, challenges, sorrows and joys of being a nurse, seen through the voices and lives of nurses today.

You can see more on this Facebook page – ON Nursing Excellence


News Roundup VoiceofTheDoctor today at 2:30 on #healthcare #radio

Posted in Uncategorized by drnic on April 27, 2012
Todays Apr 27 is news round up on Voice of The Doctor (#VoiceoftheDr, #VotD)

Many people know we are suffering drug shortages in the area of chemotherapy drugs (Cisplatin, Doxrubicin, Methotrexate), but did you know that drug shortages in the US include some of these well known and commonly used drugs:
  • Morphine
  • Dextrose
  • Diazepam
  • Epinephrine
  • Liodcaine
  • Naloxone
  • Sodium Bicarbonate
  • Tetracycline
  • Warfarin
The complete list is available here
In fact in a recent discussion with a practicing ED physician I heard that while they were treating a patient for a cardiac emergency (crash call/code blue) the team were informed there was a limited supply of Sodium Bicarbonate and the hospital was down to the last 40 doses and use would need to be rationed….!

We will also review the following areas
  • Meaningful Use Status Check – report on latest statistics and experiences
  • ICD10 delay check in – what does it mean
  • Remote monitoring for patients and patient self engagement – sent for a big take off, what might it mean

There are three ways to tune in:

• Stream the show live – click the Listen Live Now to launch our Internet radio player.
• You can also call in. A few minutes before our show starts, call in the following number:  Call: 1-559-546-1880; Enter participant code: 840521#
• is now on iTunes Radio!  Stream the show live – you’ll find this station listed under News/Talk.

Is Healthcare Information Technology Transformational..maybe not?

Posted in #hcsm, #voiceofthedoctor, HealthIT by drnic on April 19, 2012

I’ll be joined this Friday by Roger Green a seasoned tech visionary on The Voice of the Doctor radio show at 2:30 pm ET. You can join the conversation:

  • Stream the show live – click the Listen Live Now button on the site to launch our Internet radio player.
  • You can also call in. A few minutes before our show starts, call in the following number:  Call: 1-559-546-1880; Enter participant code: 840521#
  • is now on iTunes Radio!  Stream the show live – you’ll find this station listed under News/Talk.

There is likely agreement that technology has provided innovation in the healthcare world and there is no doubt that we can point to the progress made with some ground breaking tools (CT Scanners and MRI imaging spring to mind as providing unique windows into the body)


But has this transformed healthcare in the right direction. I blogged about the challenge this technology has created back in 2008 (Doctor please look at Me not your not your EMR – the title of which came from my then 9 year old’s summary of her first hand experience with an EMR)

But it was the recent story on NPR; The Race To Create The Best Antiviral Drugs that highlighted the ongoing war on infection that is raging in hospitals, clinics and healthcare facilites that took a major step forward in 1928 when Sir Alexander Fleming noted the effect mold was having on his bacterial cultures. Step forward a few years and we are loosing our battle with our current crop of antibiotics as evidenced by the rising incidence of Methicillin-Resistant Staphylococcus aureus (MRSA) CDA Study: Hospitalizations and Deaths Caused by Methicillin-Resistant Staphylococcus aureus, United States, 1999–2005 and their chart

As Carl Zimmer highlighted when discussing the trillions of viruses (and bacteria) that live in our bodies”

Some are harmful, some may not be harmful,” he says. “Some may even help us defend against other viruses. It’s very complicated in there, and we don’t really understand it very well yet

But it was the success of a non-standard treatment that has me wondering where the transformational innovation will come from. In this case a fecal transplant – a concept many used when we ate live cultures of bacteria to help with gastro intestinal symptoms brought on following antibiotic therapy for an infection (aka as eating yoghurt when taking antibiotics). In this case a patient with an intractable infection of Clostridium Difficile was given a fecal transplant:

The patient was treated with a transfusion of gut microbials from a healthy individual’s fecal material to restore the bacterial flora in her intestinal tract. “Literally two days later she started feeling better, and a couple weeks later, when they went to sample the bacteria that was there, they couldn’t find the C. difficile anymore. It was just gone,” he says. “The only thing they had done was essentially restore her ecology, essentially like restoring a wetland.”

Seems nature has the answer once again – you could argue that was science but given the FDA has 

..a very difficult time figuring out how to come up with regulations for this …. the FDA is going to have to move beyond its old paradigm of giving people regular drugs to being able to give people tailored concoctions of living things — of bacteria, of maybe even viruses — as medical treatments

I wonder if healthcare transformation is not so much about information technology but rather the use of highly refined treatments from nature and our environment.

Roger Green and I will be discussing this on Friday – please join the conversation


Why Facebook should be a template for electronic medical records

Posted in Uncategorized by drnic on April 10, 2012

Facebook a template for electronic medical records – not as radical as it might sound at first. I blogged the same point back in 2008
A Facebook Medical Record

It sounds like Facebook would make a great starting template for a vast interconnected medical records system. But the reality is that the electronic medical record (EMR) industry is still stuck in the era of the BBS.

Open easy access that includes mandated sharing and open standards rather than the proprietary old fashion mechanism currently entrenched in the EMR systems. I’m willing to be that patients might drive this in the near future as we move to a more personalized system that is managed with individuals managing and controlling their personal health record.

Doctor Panels Urge Fewer Routine Tests

Posted in Uncategorized by drnic on April 4, 2012

The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.

“Overuse is one of the most serious crises in American medicine,” said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative. “Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message.”

Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters. But their change of heart also reflects recent changes in the health care marketplace.

Insurers and other payers are seeking to shift more of their financial pain to providers like hospitals and physician practices, and efforts are being made to reduce financial incentives for doctors to run more tests.

The specialty groups are announcing the educational initiative called Choosing Wisely, directed at both patients and physicians, under the auspices of the American Board of Internal Medicine Foundation and in partnership with Consumer Reports.

The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.

The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches. The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.

Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.

Other efforts to limit testing for patients have provoked backlashes. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.

“Any information that can help inform medical decisions is good — the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make,” said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. “With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients’ ability to make decisions themselves.”

Dr. Christine K. Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation, disagreed, saying the United States can pay for all Americans’ health care needs as long as care is appropriate: “In fact, rationing is not necessary if you just don’t do the things that don’t help.”

Some experts estimate that up to one-third of the $2 trillion of annual health care costs in the United States each year is spent on unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.

Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over a malpractice lawsuits, experts said. Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation.

Still, many specialists and patient advocates expressed caution, warning that the directives could be misinterpreted and applied too broadly at the expense of patients.

“These all sound reasonable, but don’t forget that every person you’re looking after is unique,” said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group’s advice would make tailoring care to individual patients harder. “This kind of one-size-fits-all approach can be a real detriment to good care.”

Cancer patients also expressed concern that discouraging the use of experimental treatments could diminish their chances at finding the right drug to quash their disease.

“I was diagnosed with Stage IV breast cancer right out the gate, and I did very well — I was what they call a ‘super responder,’ and now I have no evidence of disease,” said Kristy Larch, a 44-year-old mother of two from Seattle, who was treated with Avastin, a drug that the F.D.A. no longer approves for breast cancer treatment. “Doctors can’t practice good medicine if we tie their hands.”

Many commended the specialty groups for their bold action, saying the initiative could alienate their own members, since doing fewer diagnostic tests and procedures can cut into a physician’s income under fee-for-service payment schemes that pay for each patient encounter separately.

“It’s courageous that these societies are stepping up,” said Dr. John Santa, director of the health ratings center of Consumer Reports. “I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ ”

This article has been revised to reflect the following correction:

Correction: April 4, 2012

An earlier version of this article misidentified, at one point, the organization whose member groups recommend that doctors curb the use of 45 common medical tests that may be unnecessary. It is the American Board of Internal Medicine Foundation, an organization that promotes physician professionalism — not the American Board of Internal Medicine, the specialty board with which it is affiliated.

In a great new step nine of the medical speciality boards have joined together to help guide doctors and patients to help decrease the waste in healthcare.

The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.

Quite – unusual but warmly welcomed because as Dr Lawrence Smith points out “overuse is one fo the most serious crises in American Medicine”

THe list includes:
EKG’s done as part of routine physicals
MRI’s for back pain
Antibiotics for sinusitis
Stress cardiac imaging in asymptomatic patients
Lower dosage medications for acid reflux
Decreasing scans for early stage breast and prostate cancers that are unlikely to spread
Rigorous review before commencing on chronic dialysis

Look for the back lash as patients and patient advocate groups leap in as we saw when the guidance on frequency of mammography screening was reduced from annual to every 3 years. Its inevitable as you take away things that people believe are necessary and see as their right but if we don’t want to see rationing of care

In fact, rationing is not necessary if you just don’t do the things that don’t help

But tied to this as Sam Bierstock rightly pointed out in our discussion last Friday – much of this is driven by defensive medicine and fear of litigation and until this aspect fo the equation is dealt with the impact of these initiatives are likely to be muted.

Will plan on talking about the imaging aspects of this with Dr Bill Boonn (@wboonn) this Friday in my weekly discussion on #voiceofthedoctor

American College of Radiology joins 8 others in recommendations to reduce waste

Posted in Uncategorized by drnic on April 4, 2012
9 Colleges launched an initiative to reduce waste in the healthcare system and the details can be found at Choosing Wisely website. Tune in on Friday at 2:30 ET when I will be  joined by Dr William (Bill) Boonn (@wboonn) who is:

We will be discussing upcoming regulations and dosage reporting requirements and the impact technology can have in mitigating these additional reporting requirements btu will also plan on talking about the recommendations fromt eh American College of Radiology on “Choosing wisely”

Don’t do imaging for uncomplicated headache.
Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.
Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

Join me on Friday at 2:30pm at #voiceofthedoctor