Monday, April 29, 2013

Monday April 29

It has been a lazy spring weekend up to today. No earth shaking thoughts to post except some more on our decaying health care system; but after three days on one aspect of the problem a rest is needed.

There will be much more to comment on the Boston bombers and  our anti-terrorist defences; especially if something went wrong.  The answer may be that we live in a country where we have rights that are protected, often that could lead to bad results; but it is not a police state ala Putin.

I was going over an external hard drive on which several years ago I had stored unedited digital copies of over a thousand slides. Some over years had undergone deterioration and some could be only rescued in a monochrome form. These two; fishing boats and the Cabot Trail on Cape Breton date from 1949.

Like all good intentions;some day I will clean up the dust on the slides.

Sunday, April 28, 2013


Please be advised that although Sequestering has not impacted on blogging; the beautiful weekend has. This will be it until Monday.

Regarding the impact of Sequestering; isn’t it remarkable that a Congress that motivates all of its actions on Political Grounds without any regard of the nation’s welfare within four days that the laws went into effect resulting in excessive flight delays; passed legislation mitigating the restrictions on the FAA. Could it be that the emergency was detected by the fact that this week Congress is in recess and the Senators and Representatives could be delayed in leaving Washington?

Saturday, April 27, 2013


To return to the impact of the EHR upon today’s version of health care; there is a check list template that must be filled out by the examining physician at every visit no matter how small although for a minor illness brief visit the template may be shortened.

In either the health care act or Medicare rules and regulation there is a possibility for an unannounced visit by an inspector to check records to see if all items are filled. Because they are checked doesn’t mean that whatever was required was done But if it is not checked the reviewer will assume that it was not done and the physician will be subject to penalties which h may be as severe as  license revocation; a danger even if remote no doctor can ignore. The question or procedure may or may not have been done.

It should not take too many visits under these circumstances for a file to contain a voluminous amount of data. It should include all the old written record held. To go through all of it would take time; to overlook the data would be a violation of the law. It would soon become obvious that much of the data in the record is useless.

Let us ignore the fact records are only as good as the material entered. The old cliché “garbage in, garbage out” is never truer than in the medical record.

As anyone who uses a computer knows, it is possible for any file to become corrupted. If so it will be worthless. Backup storage will be needed. Since present storage is on a cloud, a theoretical server there is danger of it being hacked into. Certainly the Constitution guarantee of privacy is not safe. 

There is no electronic file that is immune from determined hacking. Also somewhere along the line there will b e human error that will expose files.

There have been studies reported in various media that the supposed cost efficiencies proclaimed for EHRs has not materialized and at least one study reported it to have increased care costs. That may be due to factoring in the initial installation costs plus annual fees.

On 9/17/12 the Wall Street Journal published an op-ed by Soumeral & Koppel; to quote:

In two years, hundreds of thousands of American physicians and thousands of hospitals that fail to buy and install costly health-care information technologies—such as digital records for prescriptions and patient histories—will face penalties through reduced Medicare and Medicaid payments. At the same time, the government expects to pay out tens of billions of dollars in subsidies and incentives to providers who install these technology programs.

The mandate, part of the 2009 stimulus legislation, was a major goal of health-care information technology lobbyists and their allies in Congress and the White House. The lobbyists promised that these technologies would make medical administration more efficient and lower medical costs by up to $100 billion annually. Many doctors and health-care administrators are wary of such claims—a wariness based on their own experience. An extensive new study indicates that the caution is justified: The savings turn out to be chimerical.

Since 2009, almost a third of health providers, a group that ranges from small private practices to huge hospitals—have installed at least some "health IT" technology. It wasn't cheap. For a major hospital, a full suite of technology products can cost $150 million to $200 million. Implementation—linking and integrating systems, training, data entry and the like—can raise the total bill to $1 billion.

But the software—sold by hundreds of health IT firms—is generally clunky, frustrating, user-unfriendly and inefficient. For instance, a doctor looking for a patient's current medications might have to click and scroll through many different screens to find that essential information. Depending on where and when information on a patient's prescriptions were entered, the complete list of medications may only be found across five different screens. “

The crux of the matter is that the EHR not only may not be kept confidential but has not been proven to be a cost effective repository of patient’s medical information. It either occupies the professional’s attention during the brief visit or requires post facto time consuming entries later in the day.

Another health care related “treatise” in a few days.

Friday, April 26, 2013


The preceding installment ended thus;” in a 2012 article in the British Medical Journal reproduced this week in the internet ‘Medscape Internal Medicine News titled The Death of the General Physical Exam “a case study illustrating this point is an example of what is happening.”

But before I continue on that subject; I am going to digress with  in somewhat complete detail  what  in my practice years from 1946 to 1990 I considered to be a  physical examination. You may compare that with the examination you get in this era. It is followed by an excerpt in length from the above article which illustrates the problem. I will return in the next posting to dangers from the EHR.

The average time was at least 45 minutes, almost all spent with the patient. I began after some brief personal interaction with patient about family, work etc. by reviewing the patient’s  record and his medication (my patients were always instructed to bring  all their medicines –prescriptions and over the counter drugs- including those  prescribed by other practioners)  in order that I could be sure they were taking what I had prescribed. During the chart review I questioned if there were any specific new health related complaints or changes in ongoing problems. We then proceed to the examine room where the patient had been instructed to strip and don a gown. Except for the late 40s when women trusted their doctor and disgruntled patients started filing false molestation suits; my nurse was always in the room when I was with female patients.

My exam was a “my routine” one starting with a visual exam of the head. The eyes were check for mobility and focusing. Certain motions of the eyes could be significant of brain or other neurological disease. Ophthalmoscope examination of the interior of the eye was standard. Otoscopic exam of the ear followed and included a tuning fork hearing test. The mouth and was examined for lesions as well as the pharynx and tonsils. The facial muscles were checked for any lack of mobility.

The neck was palpated for nodes and masses in the thyroid including swallowing. The carotids were listening to for murmurs. This was followed by checking motion and flexibility of the arms along of course with inspection. Included was palpating the axilla for nodes.

The blood pressure was checked in both arms without the interposition of clothing. A difference in arms could signify some arterial obstruction.

After inspection of the chest the exam consisted of palpitation, percussion and listening. Both front and back. There were several elements of the auscultation that were important in eliciting disease in the lung. This was critical in finding suggestions of pneumonia, tuberculosis and all other lung pathology. If any abnormalities were found that would be indication for x-ray.
The heart was listening to for murmurs in all four valve areas as well as rhythm abnormities.

Women had a manual breast exam.

The abdomen was palpated in all quarters for masses or tenderness, and the bowel was listen do for quality and character of sounds.

The groin area was checked for hernias and lumps. In males the testicles were felt for masses.

The lower extremities were of course visually checked and the pulses in the feet were determined. Knee jerk, ankle and Babinski reflexes were always checked since abnormalities could be indicative of neurological disease.

All patients had a rectal exam including a test for stool blood. All women had a manual and visual vaginal so that the ovaries as well as the uterus could be checked. Those above a certain age or with suspicious areas on the cervix had a Pap smear sent to the lab.

Before disrobing patients were checked for balance and finger to nose tests.

All patients after an age level had an EKG which I read. Today they are almost routine because the machines computer reads the tracing and prints a report based on its programming. A percentage of these reports which are no better than the programming are erroneous due to subtle changes.

I also did both a PA and lateral chest in my office after a certain age or if symptoms or history suggested. We did a routine urine check and drew blood for a CBC and a large panel which was sent to the commercial lab.

The fee for this exam was a prorated one based on the anticipated time compared with the usual office visit plus the EKG and x-ray.

When was the last time your physical came close?  Doctors cannot afford to spend the time needed for the reimbursements received. Moreover they have to justify any extra studies requested.

I am almost as exhausted from writing this as a patient would be after the exam. 

To return to the British Medical Journal article; the author related a physical exam that a resident whom he was supervising was performing. To quote;  
“At a time when the cost of healthcare is under intense scrutiny, it is clear that the goals and structure of the general health examination need reform if it is to continue to survive. The current review examines the results of an important systematic review of the general health examination and offers ideas on a way forward.

"I have a 58-year-old woman here for a general health exam," the resident reports. It is early in the clinic day, an optimistic time before complicated cases and last-minute patients upset the rhythms of teaching and patient care. My assignment is to shepherd this patient safely through her clinic visit with one of our senior residents, and teach the resident a thing or 2 in the process.

The resident's presentation schusses forward, like a competitive skier navigating the gates in the giant slalom. HPI (history of present illness), PMH (past medical history), PSH (past surgical history), meds, allergies...all moving along. Everything is going just as planned.

The last finding in the resident's 18-item review of systems is painless vaginal bleeding for 3 months. And then he is off to the physical examination.

OK, I'm thinking, hang in there. The resident will circle back to the bleeding issue. Surely it will be featured during his presentation of the examination. Maybe something really important is coming.

The resident performs a head-to-toe physical examination but, amazingly, a highly incomplete one. 

When presenting the assessment and plan, he has a thorough understanding of the patient's hypertension, her mild left lateral epicondylitis, and her insomnia.

Last, the resident mentions this patient's vaginal bleeding. He recommends a women's health screening examination at her next appointment 1-2 months from now. She can have a proper examination and evaluation at that time.

This resident queried shortness of breath in this patient with no risk factors. He examined her tympanic membranes. He will order laboratory testing that includes her serum chloride and bicarbonate levels. But he did not acquire further history regarding her vaginal bleeding. He did not perform a pelvic examination.

"What is the number-one concern regarding this bleeding?" I ask.

"Cancer," he responds correctly.

"So why not perform a better evaluation of this patient's cancer risk right now?"

"I guess I thought that the patient was here for a general exam, so I focused on that. That form is really long."

We are seduced by technology, the cost factors, and planners words to believe that we are getting what we think we are. That and the EHR deludes us into believing that modern day medicine will make us a healthier nation.
Part 3 next;(back to the HER and other internet transmitted data, such as X-rays.

Thursday, April 25, 2013


On April 15 at the conclusion of my blog on that day's blog WHO IS TREATING WHOM ? bemoaning the  deterioration of the human element in health care I promised that the next essay would be on the “flimflam of the Electronic Health Record, (EHR).

In the last four decades the HMOs, economics, public expectations and demands, a litigious society, the Internet, and the computer age all have had a drastic impact upon our health care system. Without going into the negative technical  concerns raised by the explosion of computer generated documents; the darling of all theorists the HER EHR* has had some of the greatest influence on how we receive today’s health care.

As the law now stands I believe starting in 2014  Medicare  doctors who do not convert to EHRs will, be penalized by reduced reimbursement. The percentage decrease increases each year,
As has been noted in blogs for the past three years the false fascination with electronic records has been a prime force by the social theorists who hold sway in this budding electronic age. Several large software vendors along with hardware producers had actively lobbied for the inclusion of this non-option into PPACA.

The theory has merit; if all of a patient’s health history including diagnoses, examination, tests and other studies were available to an examining health care provider unnecessary duplication could be prevented thus saving costs.

However this fetish has created unexpected consequences: One problem lies in the fact that the equipment and software are expensive, and some represents an annual cost creating a burden that an individual or small group can find overwhelming. That has resulted in the coalescence into large groups many being sponsored by hospitals.

One disadvantage of large groups is the creation of a basic  impersonality in patient and physician relationships. The physician works under the pressure of production quotas and much of the actual patient care is delegated to the NP or PA.

Another difficult lies in the fact that proprietary software doesn’t always communicate with other similar programs.  There are about three software vendors who focus on large groups and hospitals. There are an additional dozen or so smaller  vendors that are economically better for the individual or small group practice.

Other unintended by  the health care reformers with the insistence on EHRs  is the templates that have to be completed at each visit . Without their presences it is assumed that the patient did not get proper treatment and  payment would be denied.

Yes or no check boxes are assumed to be evidence that the questions were actually asked or the desired information obtained and assimilated. A great deal of the “Provider” team’s time with the patient is devoted to filling out the form  and actual hands on relationship has become as thing of the past.

Under all programs be it Insurance plan or Medicare the emphasis has been on broad reviews for potential disease under the annual Health Care exam. Instead, the general physical examination among adults should focus on specific evidence-based goals of preventive medicine.

In an 2012 article in the British Medical Journal reproduced this week in the Internet ‘Medscape Internal Medicine News titled The Death of the General Physical Exam  a case study illustrating this point is an example of what is happening.
The next installment will be up by tomorrow. 
*Both Word and the Blog insist on changing the acronym EHR to HER. They must be sexist.