E-consult company AristaMD acquires referral management platform developer Preferral for an undisclosed sum.
Healthcare advisory and analytics firm Press Ganey acquires Forsta, a customer experience and market research technology business.
Neura Health Raises $2.2M to Improve Access and Quality of Care for Neurologic Conditions
Neura Health, a membership-based virtual clinic specializing in treatments for headaches, raises $2.2 million in seed funding.
As a consulting clinical informaticist, one of the things I’m often tasked with is EHR optimization. Sometimes clients have robust structures for receiving feedback from clinical users as well as teams who are tasked with assessing workflows and recommending changes. In those situations, I might provide clinical input as they work through issues, getting proposed changes polished before we take them out to stakeholders for feedback. That’s a lot of fun, because the end users appreciate having a fully vetted solution presented to them versus having to be involved in the details of process.
Other times, clients need someone to help them create a structure to handle feedback and recommend solutions. Those projects are also rewarding because users really like feeling like they’re being heard and that someone cares, even if the process you’re creating is just getting started.
One of the hot topics in optimization right now is figuring out how to lighten physician documentation requirements. It’s been a year since the Centers for Medicare & Medicaid Services modified the Evaluation & Management coding requirements with the goal of simplifying documentation. Many clinicians thought the changes were too good to be true and I don’t blame them. Coming from a large health system background, I felt that the years of internal compliance audits had created a certain level of fear around under-documenting or over-coding. We had been conditioned to make sure we were documenting more than enough Review of Systems and Physical Exam checkboxes just to be on the safe side. This was made more complex when one needed to document an element that could be counted in two different systems, and most of the physicians I know had come to dread any conversation around coding.
Now that there has been some flexibility, and people have learned that auditors aren’t waiting around every corner to catch someone who isn’t documenting correctly, physicians are eagerly pushing their organizations to remove the excessive clicking that physicians and their support staff members have been complaining about for years. As people have reassessed their priorities during the pandemic, clinical users have been increasingly vocal about how much they feel technology is contributing to burnout. With staffing levels as dire as they are in some organizations, those organizations have figured out that they can’t afford to not listen to what their employees are saying. Those organizations who have consciously looked at how their users work have also figured out that so-called “note bloat” makes it harder to care for patients since notes that contain extraneous information make it harder to find the data elements that are important.
Physicians and other users who had created extensive macros to satisfy the previous E&M requirements are now spending time trimming down the content of those macros to better reflect what they do in a typical patient visit. Adjusting those configurations takes time, and end-users are eager to have an analyst or super user make the changes whenever possible. Depending on the EHR, the effort needed to do this can range from straightforward to cumbersome. Not surprisingly, I see more progress on “easy” systems than I do on those that require greater involvement of IT or other teams. Sometimes the level of difficulty to make a change is murky, though. The fact that I’ve worked in so many different EHRs is certainly an advantage when analysts push back and try to make it seem like it’s more complicated to make a change than it really is.
I also see more physicians who are using time-based coding since figuring out how to document that has become a bit easier. In the past, you had to keep track of how much of the visit was face-to-face, how much was counseling and coordination of care, etc. Now the majority of elements performed by a provider on the day of service count, making it much more likely that a physician might choose to code based on the duration of effort. This has led to greater number of high-level visits being coded by physician. Although one would think this should lead to greater pay for physicians, I’ve seen a number of organizations figure out ways to avoid paying their clinicians more. Some have made adjustments to keep physician salaries relatively flat, keeping a greater portion of the payments for the organization versus passing them on to the people doing the work.
When I hear that the latter is happening, I try to push optimization as much as possible in order to ensure the end users feel some relief. Even if they’re not receiving better compensation, I can hopefully make their days at least a little bit shorter and their visits a little easier.
There have been a couple of times recently when I’ve felt really torn when working on an optimization project. I’ve gotten a sense that administrators will perceive that the physicians are doing less work, will translate this to a perception that the physicians have greater capacity, and then continue to shift work towards them. We saw a great shift of low-level clinical work to physicians at the beginning of the Meaningful Use program, and physicians had to fight hard to get organizations to agree that they needed their support staff to take on some of this work. The idea of working at the top of your license could be used to show that physicians were expensive, and if you had more staff, you could see more patients and those changes were revenue neutral or even positive.
Now that there is such a labor shortage, finding capable staff at a price organizations and administrators are willing to pay can be tricky. Not surprisingly, physicians have filled the gap because it’s the right thing to do for their patients, but it’s hard to convince decision makers to look for unicorn-like staff members in this market when they know the physicians will do the work for free. No amount of optimization is going to improve clinician morale if they feel like they’re being pulled into a black hole of ongoing work with no help in sight. I’m interested in understanding how large organizations have optimized their systems based on the changes to the Evaluation & Management codes.
Are your ambulatory physicians writing the shortest notes of their careers with the same billing codes? Leave a comment or email me.
Email Dr. Jayne.
Torbjörn Kronander, PhD, MSEE, MBA is president and SEO of Sectra of Linköping, Sweden.
Tell me about yourself and the company.
Sectra started out as a cybersecurity company in Sweden. In 1990, I had just completed my PhD and started up the medical imaging side of the business. Our first foray was in teleradiology and then we moved into radiology. We took what we learned in radiology, and we’re now focusing on enterprise imaging and have added modules for cardiology, ophthalmology, orthopedics, and pathology.
We are seeing the same trend in imaging that we’ve seen in EMRs, where there was a separate information system for every single department of the hospital. Then Epic and Cerner came around, and the CIOs said, we want as few systems as possible, and consolidated all the departmental information systems on one EMR.
What are the most significant trends in medical imaging?
Efficiency is important. There is an alarming risk of burnout among US physicians. You need to have systems that are fast and effective to use.
We see a trend toward consolidating to as few IT systems as possible. Having multiple systems is expensive and people underestimate the costs involved. You may have 100 IT people on your staff in a hospital, but without consolidation, a lot of them are doing the same thing on different systems. We are the only vendor who can manage all images in one system.
Cloud is also becoming increasingly important. Having a lot of hardware on site is expensive, and it is challenging to stay on top of the many updates of the underlying operating systems. If you can use Google or Microsoft to manage the cloud operations, they are, cybersecurity-wise, in a better place than almost any on-prem solution.
Combined, we see a large trend towards cloud and a single system for all your images — let’s call it a “pixel EMR,” which is a quote from one of our customers — and then within that space, digital pathology, which is rapidly coming along.
What role does AI play?
AI is very interesting. It will be large, but it will not be as fast as people anticipated. There is a famous quote that the first law of technology is that we always overestimate the impact in the short term of transformative new things, but we also inevitably underestimate the long-term impact. We see this exact trend in AI.
AI is not where it was a few years ago, when people predicted there will be no more radiologists needed to be trained after 2022, which of course is not a bit true. But we will see AI gradually coming into prominence. I’d like to quote one of our customers, Dr. Langlotz of Stanford, who says, “AI will not replace radiologists, but radiologist who use AI will replace radiologists who don’t.” It will drive efficiency, but it will not replace the radiologist. You will still need that human being in medicine.
We see a lot of AI vendors right now in the market. At Sectra, we have said that you can’t compete with the hundreds and hundreds of AI startups, so we are going with the open systems approach. We have the Sectra Amplifier Store, where customers can use any AI application that they like. If we’re going to accept the AI software for their use, we will do the cybersecurity evaluation on it and ensure that it is secure.
Cybersecurity is a grossly underestimated trend in medical IT systems, because ransomware attacks are increasing, and healthcare is a primary target. Eighty-five percent of Sectra’s business is medical IT, and the other 15% is cybersecurity, which gave us our name — “SECure TRAnsmisson.” We are one of the most prominent cybersecurity vendors in all of Europe. We protect networks with high-level security. We provide secure mobile workplaces and phones for the entire European Union. We are using that same knowledge when we build our IT systems.
Is the company’s cybersecurity expertise a competitive advantage over companies that just sell imaging systems?
That is a very true statement. For many years, we have run our security and medical divisions in parallel. Over the last two to four years, this philosophy has increased in value. Cyberthreats are dangerous for healthcare because typically health systems have to pay the ransom. If other industries get attacked by ransomware, most of them will not pay if they can at all avoid it. But in healthcare, patients die unless you pay those who are responsible for ransomware. The cyber mafia knows this.
We see huge benefit from having defense-level and national government-level security knowledge in the company. We build our systems to be as safe as possible. We are one of the highest-ranked cybersecurity companies in the entire medical sector today. To have that knowledge in house is important. It’s also interesting to see that KLAS now ranks vendors for their cybersecurity preparedness and they consider Sectra to be very mature and safe in that aspect.
What challenges and opportunities have arisen due to the pandemic, especially with telehealth and teleradiology?
I would say the largest impact has been in telepathology. Pathologists are embracing the ability to digitally send images for second opinions as well as to read from remote locations. Previously, a pathologist had to sit at the site of the biopsy and wait for the sample to arrive from the operating room. Now they can see the slides digitally and make quick and easy diagnoses.
How would you assess the status of image sharing?
That is an important question, because sending images in a taxi from one end of New York City to the other is not very effective and it’s also dangerous for the patients. Sectra has the largest image-sharing network in the world, located in the UK, in which every single hospital is connected through our system which sends approximately 40,000 exams per week. There are no CDs in the UK anymore, thanks to us. We are also applying this technology to some places in the US, but the UK network is our biggest reference as of today.
How much of the company’s strategy and product design has to reflect the healthcare policies of the US that don’t apply anywhere else in the world?
The US is our most important market at this time. We have a market share of greater than 50% in many Northern European countries where we operate, whereas we have about 10% in the US. We do, however, have the happiest customers, as evidenced through KLAS and the Best in KLAS awards, and that gives us the ability to grow. We have some important American partners that we collaborate with for research, and some very prominent hospitals as customers. We spend a lot of effort and emphasis on the US market.
There are differences between regions in the world, but not as many as you might think in the imaging space. Images are images, and the way you need to work with them to complete the diagnosis is very similar in all countries.
You’ve said that the way you beat big imaging competitors is to have better employees, stick with your goals, and treat your customers better. How do you make that happen as a global company?
I’m a good friend with Judy Faulkner of Epic, and she told me once that the only way you can become big in the US is by having more happy customers. That resonates very well with my basic philosophy of life. You need to make money, but there’s more to life than money. Happiness is also very, very important. You cannot create happy customers without happy employees. We work a lot with employee satisfaction and recruiting to finding the best people.
It’s very interesting that the competitive advantage for product innovation is a fairly short timeframe. If a vendor introduces a new feature, by the next year, everybody has it embedded in their product. But that’s not the same thing with customer satisfaction. The only way you can sustain a high level is if you have happy employees who are motivated and who will do the best for customers. That culture will always win.
We also recruit the best possible people to join the company. I personally interview every single one, worldwide, before they get an offer. To maintain exceptional quality, every interviewer has the right to veto a candidate. We also have high employee retention, with many people working at Sectra for 15 or 20 years because they like it. And of course, if they like it, they also do a good job for our customers.
What will be important to the company over the next few years?
As I mentioned earlier, enterprise imaging is crucially important. The CIOs cannot afford to have multiple IT systems and they need to partner with companies who can manage all their departmental images in one single system. We have changed to a subscription-based, SaaS model which allows the customer to acquire new technology without large capital investments and we guarantee the cost for the underlying cloud infrastructure which no other vendor does, to our knowledge.
Premier, Inc. Reports Fiscal Year 2022 Second Quarter Results
Premier reports Q2 results: revenue down 10%, adjusted EPS $0.73 versus $0.65, beating Wall Street expectations for both.
Ventilator manufacturer Vyaire Medical warns users of certain models to turn off the HL7 communication option after customers reported that the devices “unintentionally ceased ventilation during clinical use and require rebooting to resume ventilation.”
HHS: Conti ransomware encrypted 80% of Ireland’s HSE IT systems
HHS publishes a threat brief dissecting the ransomware attack that disrupted Ireland’s health service for four months.
Premier reports Q2 results: revenue down 10%, adjusted EPS $0.73 versus $0.65, beating Wall Street expectations for both.
The pandemic caused an 18% drop in supply chain revenue, while the company’s Performance Services segment – which includes analytics software – saw a 15% revenue increase. PINC shares are up 7% in the past 12 months versus the Nasdaq’s 2% gain, valuing the company at $4.5 billion.
From the earnings call:
From Bob Pshaw: “Re: the HIMSS BrandHIT Marketing Summit. I just realized that this HIMSS conference, which launched in 2017 to help vendors sell stuff, seems to have died quickly and quietly. Heard anything?” The conference, which was presented by HIMSS Media in a startling display of not even pretending to be journalistically objective, seems to have lasted two iterations, one in Las Vegas and the other in Nashville. That’s not exactly a testimonial to the topic in which it claimed expertise, and neither was the inconsistent name that HIMSS used to promote it (sometimes calling it Brand HIT, others BrandHIT, sometimes both in adjacent sentences). I assume HIMSS Media still runs its Media Lab, which sells marketing services, content, webinars, and basically paid access to HIMSS members.
Poll respondents show a preference for self-scheduling via a webpage rather than an app. Mario brings up the point that contactless appointments don’t triage based on patient need and are therefore problematic, while Rebecca notes that her least-favorite scheduling option is when the practice just tells her when to show up without asking first.
New poll to your right or here: Which factor would most entice you to seek information from a conference booth exhibitor?
Listening: Bartees Strange, who joyously follows his ear in veering from hard-charging rock to melodic hip-hop and making it all sound good.
Welcome to new HIStalk Platinum Sponsor Enlace Health of Columbus, OH. The Connected World of Enlace empowers payers, providers, and patients to participate together in an economically sound environment. Enlace Health solves healthcare from the inside out, fixing healthcare at its core. The Enlace solution is the only end-to-end infrastructure that bridges the gap between the current, chaotic system and an orderly healthcare world. Enlace always meets clients where they are, creating solutions based on need and maturity in value-based care. Enlace is Sustainable Healthcare. Delivered. Thanks to Enlace Health for supporting HIStalk.
I found this introductory video for Enlace Health on YouTube.
Thanks to the following companies for recently supporting HIStalk. Click a logo for more information.
February 9 (Wednesday) 1 ET. “2022 – Industry Predictions and Medicomp Roadmap.” Sponsor: Medicomp Systems. Presenters: David Lareau, CEO, Medicomp Systems; Jay Anders, MD, chief medical officer, Medicomp Systems; Dan Gainer, CTO, Medicomp Systems. The presenters will provide an update on the health IT industry and a review of the company’s milestones and insights that it gained over the past two years. Topics will include Cures Act implications, interoperability, AI, ambient listening, telehealth-first primary care, chronic care management, and new Quippe functionality and roadmap.
Previous webinars are on our YouTube channel. Contact Lorre to present your own.
Shares in the Global X Telemedicine and Digital Health ETF (EDOC) dropped 10% in the past month versus the Nasdaq’s 11% loss. Digital health stocks have been on a tear lately, “tear” being the kind that pours from the eyes of investors who have watched their former high-flying companies auger into the hard ground of reality, especially those that took the SPAC back door. Private equity seems better suited lately to make startups successful compared to taking those companies public prematurely to ride an investment wave-slash-bubble, so we may see more companies exiting public markets after short, unsuccessful visits there.
Terri Sanders, MPH, formerly chief marketing and communications officer of HIMSS, joins Kivvit as managing director.
Labcorp launches OnDemand, which allows consumers to buy lab tests online and either collect samples at home or at its patient service centers. Competitor Quest offers a similar service, which is also marketed through Walmart. Physicians approve the tests behind the scenes in both cases, in Labcorp’s case via PWNHealth, for which Labcorp absorbs its $6.50 fee in the test purchase price.
Ventilator manufacturer Vyaire Medical warns users of certain models to turn off the HL7 communication option after customers reported that the devices “unintentionally ceased ventilation during clinical use and require rebooting to resume ventilation.”
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SOC Telemed to be Acquired by Patient Square Capital
Healthcare investment firm Patient Square Capital will acquire acute care telemedicine platform vendor SOC Telemed for about $300 million.
Baker Tilly Acquires Orchestrate Healthcare
Advisory CPA firm Baker Tilly, US acquires Orchestrate Healthcare, which offers consulting services for EHR implementation, analytics, IT security, and health IT staffing.
Change Healthcare Inc. Reports Third Quarter Fiscal 2022 Financial Results
Change Healthcare reports Q3 results: revenue up 10%, adjusted EPS $0.36 versus $0.34, meeting earnings expectations and beating on revenue.
‘The darkest, most bottomless pit in healthcare:’ Goodbill raises $3.4M to tackle medical billing
Hospital billing and payment transparency software startup Goodbill has raised $3.4 million in seed funding.
Healthcare investment firm Patient Square Capital will acquire acute care telemedicine platform vendor SOC Telemed for $3 per share, about $300 million. That is a 366% premium to the company’s closing share price Wednesday before the announcement.
SOC went public via a SPAC merger in November 2020, with shares opening at $10.
TLMD shares had dropped to around 60 cents prior to the acquisition announcement, with a market cap in the $65 million range
SOC Telemed’s Q3 earnings report from November 2021 showed a loss of $11 million on revenue of $27 million.
Welcome to new HIStalk Platinum Sponsor NeuroFlow. The Philadelphia-based company provides best-in-class technology and care services for the effective integration of behavioral health. NeuroFlow’s HIPAA-compliant platform supports over 14 million users across 300 health systems, payors, and organizations, helping them capture behavioral health insights and take action to proactively manage individuals and populations holistically. I noted that co-founder and CEO Christopher Molaro, MBA graduated from West Point and served as a US Army platoon leader deployed to Iraq. Thanks to NeuroFlow for supporting HIStalk.
I found this YouTube video from NeuroFlow that explains how the company’s technology supports organizations that embrace the collaborative care model.
February 9 (Wednesday) 1 ET. “2022 – Industry Predictions and Medicomp Roadmap.” Sponsor: Medicomp Systems. Presenters: David Lareau, CEO, Medicomp Systems; Jay Anders, MD, chief medical officer, Medicomp Systems; Dan Gainer, CTO, Medicomp Systems. The presenters will provide an update on the health IT industry and a review of the company’s milestones and insights that it gained over the past two years. Topics will include Cures Act implications, interoperability, AI, ambient listening, telehealth-first primary care, chronic care management, and new Quippe functionality and roadmap.
Previous webinars are on our YouTube channel. Contact Lorre to present your own.
Advisory CPA firm Baker Tilly, US acquires health IT consulting firm Orchestrate Healthcare. Baker Tilly says it will continue to invest heavily in digital health to support providers who need to control costs and adopt new business models while continuing to deliver high-quality care. The company has 3,150 healthcare organization customers. The 120-employee Orchestrate offers services for EHR implementation. analytics, IT security and health IT staffing.
Relaxation app vendor Calm acquires Ripple Health Group, which offers a care coordination platform. Ripple’s CEO will serve as co-CEO with Calm’s founder and the combined companies will develop a replacement for its Calm for Business app.
Change Healthcare reports Q3 results: revenue up 10%, adjusted EPS $0.36 versus $0.34, meeting earnings expectations and beating on revenue. Its acquisition by UnitedHealth Group remains on track for sometime after February 22 and before its deadline of April 5.
Shares in Meta (Facebook) tanked 26% Thursday after the company reported its first-ever decline in quarterly user count and it warned of expected weaker revenue growth. The resulting $230 billion loss in market value was unprecedented. Meanwhile, Amazon’s shares jumped 17% in after-hours trading after it reported strong earnings and another increase in Prime annual pricing to $139, increasing its market value by around $250 billion.
Drug discount management platform vendor Kalderos names industry long-timer Brent Dover (Commure) as CEO.
Nym Health, which offers autonomous medical coding, hires Or Peles (Tasq.ai) as SVP of R&D.
Behavioral health EHR/PM vendor Kipu Health appoints Andy Eckert, MBA (Zelis) as board chair.
Real-world oncology data platform vendor COTA promotes Paige Whitney to SVP of life sciences.
Impact Advisors hires Randy Notes, MPH (RSM) as managing director of its margin improvement practice.
Eisenhower Medical Center (CA) hires Ken Buechele, MBA (Bronson Healthcare Group) as VP/CIO.
Availity hires Nathan von Colditz (McKinsey & Company) as chief strategy officer.
Janice Wurz (Scottsdale Institute) joins Garner as executive partner.
Pam Arora, MBA (Children’s Health) joins the Association for the Advancement of Medical Instrumentation (AAMI) as president and CEO.
CliniSys, which just acquired Horizon Lab Systems and merged with Sunquest Information Systems, names industry long-timer Mark Spencer (Abbott Informatics) as SVP of global strategy.
Memorial Health System Cancer Center (OH) implements Sonifi Health’s interactive platform, which offers on-demand movies, relaxation content, educational programs, and live programming.
A study finds that patient-generated behavioral health data can be reliably submitted via NeuroFlow’s app and was associated with a 50% reduction in suicidal thinking.
MedStar Health goes live on a patient experience platform from B.well Connected Health.
MyConnectSolutions adds virtual care capabilities to its MedConnect platform, powered by Bluestream Health.
Walmart will offer customers the ability to order lab tests from Quest’s QuestDirect online. Their order will be approved by a doctor when required and the company will then either mail the customer an at-home test kit or direct them to a Quest patient service center, depending on the test’s requirements. The patient can share their results with their doctor via Quest’s MyQuest portal.
I ran across MedLion Clinic, which provides a glimpse into the commoditization of virtual primary care. The company’s “unlimited” plan costs $13 per month and offers customers in about half the US states 24×7 texting with an assigned doctor, scheduled video visits weekdays 9-6, management of both acute and chronic conditions, ordering of prescriptions and labs, and access to $1 medications.
The New York Times looks at the use of surveillance tracking by some cities in Japan to find people with dementia who wander, which is the leading cause of its missing persons cases. The country has adopted an “age in place” focus that leads to more wandering incidents. Digital solutions include security cameras, shoe-worn tracking devices, and QR tracking codes on the person’s fingernail. Caregivers initiate the registration process with a medical review required for approval, but individuals themselves are not required to give permission.
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For many companies, HIMSS preparation is in full swing, if my inbox is any indicator of the situation. Multiple marketing people have reached out inviting me to visit their booths for demos or conversation. I must say that the invites for happy hour appetizer and beverage events seem to be lacking, so I’m wondering if HIMSS is clamping down on food and beverage service in the exhibit hall due to COVID. If that’s the case, I’ll definitely be missing the scones.
As for booth invitations, I’m more likely to respond if a company has a compelling pitch and understands that I have to visit them anonymously versus trying to get me to make an appointment, since that undermines the whole anonymous blogger vibe. No invites for after-hours events yet, so I’m not sure how this year’s social scene is shaping up just yet.
For frontline physicians, the creation of Prescription Drug Monitoring Programs (PDMPs) brought to life key pieces of technology that made a tremendous difference in patient care. I keep receiving emails from my local PDMP, asking me to approve delegate requests for nurse practitioners and physician assistants that I worked with at my former practice. Our state won’t allow non-physician providers to have an account unless they’re sponsored by a physician, which in many cases was me. There has been a lot of turnover in the physician ranks and apparently some of the new supervising physicians either don’t have PDMP accounts and therefore can’t delegate to the midlevel providers, or somehow don’t think it’s important for the providers they supervise to be able to look for patterns of controlled substance abuse or diversion. This has been going on for more than eight months, and I feel bad for the providers who don’t have access to this vital information. It’s yet another illustration why a patchwork of state laws isn’t always the best thing for patient care. On the other hand, it’s also a pretty telling commentary on the leadership of my former practice, who could solve the problem by requiring that everyone makes use of the PDMP and that appropriate operational structures are in place to support the effort.
From Jimmy the Greek: “Re: this week’s Snowmageddon. I’m tired of seeing organizations talk about their ‘inclimate’ weather” preparations. Spelling counts. Take a look at this email – not only is the inclimate weather virus spreading, but now I have contact information for 200+ patients.” Jimmy forwarded me an email from his local physical therapy provider, who apparently doesn’t understand patient privacy or how to use blind carbon copy functionality on an email. The body of the email made it clear that the addressees were patients with appointments scheduled today or tomorrow and also mentioned that they’d be contacted to reschedule. I hope Jimmy gives them an earful when he receives his call.
Hot on the heels of my weekend piece about healthcare organizations that aren’t giving their employees time to recover from illness and injury, I’m mentoring young physician informaticist who emailed with some questions about professionalism. He was on a training call with one of his organization’s tech vendors. The lead presenter seemed tired and out of it, and about 20 minutes into the call, admitted that he was COVID-positive and was having a difficult time focusing and asked if they could take a break so he could hand off to his backup. As a physician, my friend was surprised that someone who was obviously symptomatic would be working, especially in a non-essential role. From a business perspective, he was surprised that the vendor hadn’t asked to reschedule the call, or that they didn’t start the session with the backup presenter in the first place.
Even with people working remotely, if they’re not well enough to work, they shouldn’t be working. In this situation the presenter knew well enough that they weren’t 100% that they arranged for a backup presenter. This situation speaks not only to poor individual judgment (which I guess you could probably attribute to COVID-induced brain fog), but potentially to corporate policies that push people to work even when they shouldn’t.
My young colleague was wondering about what he should have done if there hadn’t been a backup presenter. Should he have called a stop to the presentation after realizing the presenter was in some distress? He was also questioning whether he should say something to others at the vendor about what had happened. I think compassion dictates asking a struggling presenter if they need a moment, and if they don’t realize there’s an issue, then I’d probably ask them if we could reschedule. It’s difficult where a medical condition is concerned and one doesn’t want to pry or appear inappropriate pointing out that things aren’t going well, so I’m not sure if there’s a great answer here.
This ties in nicely to an article I read about the CDC’s recent update to workplace guidelines for COVID-positive healthcare personnel. Although many assume those roles are largely occupied by physicians, nurses, therapists, and others who are performing hands-on patient care, the CDC guidance also includes “persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting,” including administrative and billing personnel. This also may include a lot of healthcare IT workers depending on their roles. Many healthcare workers who aren’t in the weeds on the recommendations might not realize that work restrictions for healthcare personnel are broken into three categories:
We’re starting to come down from crisis standards of care to contingency in some parts of the country, and in others, it may be time to see a change from contingency to conventional standards. Regardless of the definition, if people aren’t able to perform the essential functions of their job, they shouldn’t be working. We need to stand up for each other when we see someone in the workplace who probably shouldn’t be.
How would you handle someone who is obviously too sick to work? Leave a comment or email me.
Email Dr. Jayne.
Kipu Health appoints former TriZetto and Eclipsys CEO Andrew Eckert (Zelis) as chairman of its board.
Calm app acquires Ripple Health Group and appoints a new co-CEO
Relaxation app developer Calm acquires Ripple Health Group, which offers caregivers digital healthcare organizers and coordination with professional care teams.
Biden relaunches cancer-fighting ‘moonshot’
President Biden announces the relaunch of his Cancer Moonshot program, which aims to reduce the cancer death rate by 50% over the next 25 years, alongside the proposed launch of the Advanced Research Projects Agency for Health.
PointClickCare Technologies Announces Intent to Acquire Audacious Inquiry
Post-acute care software vendor PointClickCare will acquire Audacious Inquiry, a Baltimore-based care notification and coordination technology company.
Cancer care navigation and experience platform vendor Jasper Health raises $25 million in a Series A funding round.
VA failed to ensure data quality during initial EHR rollout, GAO finds
A GAO report finds that the VA did not establish performance measures and goals for migrating data from VistA to Cerner Millennium and HealteIntent before initial go-live in October 2020, resulting in the recommendation that the VA establish and use data performance measures and use a stakeholder register to make sure reporting needs are addressed.
Forescout Acquires CyberMDX to Expand Healthcare Cybersecurity Focus
Enterprise cybersecurity firm Forescout Technologies acquires healthcare cybersecurity company CyberMDX.
Post-acute care software vendor PointClickCare will acquire Audacious Inquiry, a Baltimore-based care notification and coordination technology company. Terms were not disclosed.
Canada-based PointClickCare acquired care coordination platform operator Collective Medical in December 2020 for $650 million. Its earlier acquisitions include Co-Pilot Analytics and QuickMar.
A year-ago minority investment reportedly valued PointClickCare at $4 billion.
February 9 (Wednesday) 1 ET. “2022 – Industry Predictions and Medicomp Roadmap.” Sponsor: Medicomp Systems. Presenters: David Lareau, CEO, Medicomp Systems; Jay Anders, MD, chief medical officer, Medicomp Systems; Dan Gainer, CTO, Medicomp Systems. The presenters will provide an update on the health IT industry and a review of the company’s milestones and insights that it gained over the past two years. Topics will include Cures Act implications, interoperability, AI, ambient listening, telehealth-first primary care, chronic care management, and new Quippe functionality and roadmap.
Previous webinars are on our YouTube channel. Contact Lorre to present your own.
Advanced care planning and virtual palliative care company Vynca raises $30 million. Vynca, which counts Intermountain, Ochsner, and Sutter health systems among its customers, acquired palliative care provider ResolutionCare last summer.
Vista Equity Partners and Evergreen Coast Capital will acquire Citrix for $16.5 billion. They will take the company private and merge it with Tibco Software, an enterprise data management company that includes healthcare providers and payers among its customers.
Seattle-based remote patient monitoring startup Measure Labs raises $4.7 million. CEO Jamien McCullum, CSO Matt Whitehill and CTO Eric Chen are entrepreneurs-in-residence at the Allen Institute for Artificial Intelligence, which the company lists as an investor.
Cancer care navigation and experience platform vendor Jasper Health raises $25 million in a Series A funding round.
Digital diabetes management company Glooko acquires Xbird, a Berlin-based company that offers diabetes-focused predictive analytics and care management.
Healthcare consumer experiences platform vendor League raises a $95 million funding round. I can’t decipher exactly what it sells, but it has implemented an impressive array of buzzwords. The three co-founders, none of whom have healthcare experience, came from Kobo, a company that sold a e-reader that attempted to compete with Amazon’s Kindle.
Nathalie McCaughley, MBA, MS (Cigna) joins Agfa HealthCare as president.
RapidAI names Karim Karti (IRhythm Technologies) as CEO.
Andrew Resnick, MD (Mass General Brigham) joins The Chartis Group as chief medical and quality officer.
Quantum Health names Veronica Knuth (CoverMyMeds) as chief people officer.
Pager names Simon Mathews, MD (Vivante Health) chief medical officer, Bulent Ugurlu (Optum) VP of engineering, and Max Anfilofyev (SOC Telemed) VP of product; and promotes Joe Martinez, RN to VP of virtual care and Alison Thomas (not pictured) to VP of partner solutions.
Jessica Beegle, JD — who has worked in healthcare business development for GE, Amazon Web Services, Google, and Walgreens Health – joins for-profit hospital operator LifePoint Health as SVP/chief innovation officer.
Allscripts promotes Salman Naqvi, MBBS, MPH to VP of professional services.
ResMed hires Urvashi Tyagi, MS, MBA (ADP) as CTO, where she will lead the company’s digital health technology team and investments. She replaces Bobby Ghoshal, MBA, who was previously promoted to president of the company’s SaaS business unit.
Hackensack Meridian Health (NJ) implements data integration, quality, and management capabilities from Informatica.
Community Hospital of the Monterey Peninsula says its use of the care management platform of Force Therapeutics helped reduce 90-day admissions following total joint arthroplasty procedures by 26%.
Azara Healthcare launches Care Connect, a care coordination application that draws data from its analytics platform and integrates it with health plan data to support outreach teams.
AliveCor launches the FDA-cleared KardiaMobile Card, a $149 credit card-sized personal ECG device that pairs with smartphones using Bluetooth to detect six common types of arrhythmias. Purchase requires signing up for a $99, automatically renewing annual membership.
A GAO report finds that the VA did not establish performance measures and goals for migrating data from VistA to Cerner Millennium and HealteIntent before initial go-live in October 2020. The VA concurred with GAO’s recommendation that it establish and use data performance measures and use a stakeholder register make sure reporting needs are addressed. The VA notes that any VistA data can be extracted, packaged, and sent to Cerner automatically even in the absence of a database model, 80% of critical reports are now using Cerner-generated data, and its data migration team is monitoring VistA for changes and patches that may require regenerating extraction code to keep data flowing.
ONC will convene the virtual education sessions of its annual meeting Wednesday and Thursday. Topics include information blocking, TEFCA/QHIN, public health IT coordination, Lantern FHIR tool update, and USCDI expansion.
A Stat special report recaps the 40-year history of what is now IBM Watson Health’s MarketScan, soon to be owned by private equity firm Francisco Partners. The business that was originally known as Medstat holds the employer-provided, de-identified records of 270 million Americans, but Medstat founder Ernie Luder expresses fears that instead of creating disruptive healthcare change in the insurance industry as he had hoped in the pre-Internet era, consumers are losing control of information about them as companies profit from it without their express permission. An attorney and bioethics professor says that the federal government has allowed big businesses “to run amok without almost any regulation whatsoever,” to the point that it’s easier for academic researchers to buy their data from private companies.
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Vynca Secures $30 Million in Funding to Expand Integrated Palliative Care Platform
Advanced care planning software vendor Vynca raises $30 million in a funding round led by Quest Capital.
Vista Equity Partners and Evergreen Coast Capital will acquire Citrix for $16.5 billion and merge it with Tibco Software, an enterprise data management company that includes healthcare providers and payers among its customers.
Remote patient monitoring company Athelas achieves a $1.5 billion valuation after raising $132 million in two funding rounds.
A physician friend has been waiting patiently to have a surgical procedure, which has been cancelled multiple times due to COVID. The first time it was due to the rapidly rising omicron peak, and the second time due to overall staffing challenges.
She has been patiently dealing with the delays despite the fact that she’s in a great deal of pain, and also despite the disruptions it’s causing to her practice, when she had to cancel and reschedule six weeks’ worth of patient visits, only to have to try to get them back on her schedule after the procedure gets canceled. Her patients love her and have been accommodating, but now that some of them have been through the cycle twice, I’m sure their patience is wearing thin.
In addition to moving her work schedule, she’s had to rearrange the schedules of others who had planned to come stay with her post-op, rearrange planned meal deliveries, rearrange delivery of durable medical equipment, and more. People who don’t understand what goes into procedure scheduling might not understand all the dominoes that fall when there’s a change to what should be a standardized process. Labor shortages in healthcare continue to be an issue, and she’s hoping the surgery goes ahead this week as planned so she can start recovering and getting back to the things she liked to do before her injury.
Her experience has made her more aware of what’s going on in her health system and how both individuals and the organization are responding to those who need to take medical leave. From talking to others in similar positions, it’s a reflection on what’s happening in the workplace as a whole, and why so many people are choosing to be part of the Great Resignation that’s under way.
When she first tried to schedule surgery, she had immense push-back from her department. It sounded out of proportion given that she’s a 20+ year employee who has never taken more than her usual accrued vacation time – no family leaves, no medical leaves, no bereavement leave.
Even though it’s not department policy, her department chair expected her to make up her on-call days, and went as far as to tell her she should double-up on call before she goes out (despite the fact that she is already having difficulty doing her very physical job due to her injury). She had to check her contract and threaten to get an attorney involved before they backed down. The contract clearly says that she’s not on the hook for call that she can’t take during a time of disability or incapacity. Her department is large, and she’s certainly done enough coverage for her colleagues for their various leaves over the years, so I encouraged her to not feel guilty about taking the time she needs to recover.
One colleague went to far as to tell her that since they can do some visits via telemedicine, she shouldn’t take a medical leave and should just work remotely and cover her own inbox and messages. I guess that colleague thinks it’s OK to practice medicine while taking post-operative opioid pain medications. Apparently, they also missed the part in medical school where we’re supposed to understand that patients need to rest and recover for optimal healing.
We were chatting about this on a virtual happy hour with a couple of other physicians when another friend mentioned that her hospital-owned group had told women who were on maternity leave that they had the option of coming in to see hospital consultations that had been requested. The administrators felt those visits were quick and shouldn’t take too much time each day. I thought she was kidding until she shared her screen on Zoom and showed the proof. They weren’t even subtle about the fact that they were addressing women only. Maybe that was a rogue manager, but even so, their boss should be all over them.
That certainly seems contrary to all the messaging that healthcare providers are getting from their administrators about the need to practice self-care and build resilience. I guess those suggestions only go so far until they interfere with the hospital’s ability to move patients through the system, and at that point, self-care (or care for an infant) isn’t important.
I’m not a labor attorney, but it feels like trying to coerce someone who is on family or medical leave into performing work probably isn’t the right thing to do, regardless of what your human resources department might have suggested. Those kinds of behaviors aren’t the kind of thing that makes an organization the employer of choice in a tight labor market, either.
As physicians, we’re wired to do our best to help our patients, but I hope that physicians and other clinicians continue to just say no when those suggestions are made. I don’t think having a sleep-deprived parent who would rather be home with their newborn leads to the highest quality care. Nor does having a clinician who is in a rush to get home before their childcare resource has to leave. There are plenty of studies that show that at a certain level of sleep deprivation that people are as cognitively impaired as they would be if they were under the influence of alcohol.
If this level of pressure is being applied to physicians who have a high level of education, autonomy, financial resources, and insight, it makes me wonder what strategies administrators might be using on staff members who might have less understanding of their rights or who are more afraid to push back.
What makes this even more shocking is how starkly it contrasts with what I’m seeing in other parts of the industry, where companies pride themselves on their culture and on making sure their employees feel valued. Being able to recover properly after surgery shouldn’t be a boutique ask from a culture-centric employer, it should be a basic human right. Similarly, being able to take one’s federally protected family or medical leave shouldn’t involve coercion, pressure, or the guilt treatment.
It will be interesting to see whether these organizations figure out that their tactics are counterproductive, or whether they continue to run their workforce into the ground.
Have you seen any unusual HR tactics during the labor shortage? Leave a comment or email me.
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What The (Behavioral) Health? Let’s Shift the Focus from Access to Care to Quality of Care
By Eric Meier
Eric Meier, MBA is president and CEO of Owl of Portland, OR.
Expanding access to care has been a top challenge over the last two years in behavioral health due to a significant increase in demand for treatment services. Fortunately, traditional providers and new market entrants have quickly responded to this need and dramatically increased virtual care through telehealth and digital offerings to improve access for communities across the country.
While expanding access to care should and will remain a priority, the conversation should now include, are we providing quality care to improve outcomes? Are people actually getting better through our behavioral health services?
Delivering quality behavioral health services is focused on delivering the right treatment to the right person at the right time for the right duration. Essentially, quality is defined as effective and efficient delivery of care that improves patient outcomes at the lowest cost of care.
Now that we’ve defined quality, how do you know how to achieve it? That’s where the focus on measurement comes in. Measurement of health outcomes and quality in physical health is the status quo, but it isn’t yet a consistent practice in behavioral health.
Imagine if the nation had a hypertension crisis and we spent half a trillion dollars to get patients seen by a physician, yet failed to measure their blood pressure on an ongoing basis to confirm they were delivering quality care that improved patient health. That just doesn’t make sense in physical health, and with the availability of advanced and easy-to-use measurement-based care (MBC) technology, it doesn’t make sense for behavioral health either.
MBC incorporates the longitudinal use of evidence-based measurement assessments to gather patient-reported outcomes. This tool captures symptomatology as well as progress throughout treatment. The data from MBC provides clinicians with actionable insights to personalize treatment in real-time to therefore optimize patient care.
Two critical success factors of a MBC strategy are strong patient engagement (i.e. 90% of your patients are completing the assessments at their convenience, on any device, throughout treatment) and consistent, standardized use of MBC throughout the organization as part of patient care regimen. Armed with this critical data, organizations are equipped to screen and triage patients to the right level of care, individualize treatment based on each patient’s unique symptomatology, and guide the treatment plan to know when to step the patient up, down, or out of care.
Furthermore, behavioral health organizations are starting to recognize the critical role that MBC-derived data will play as the foundation for value-based reimbursement contracting. It is precisely these data insights that will prove how patient populations are improving and how your organization is delivering quality care. This data transparency on patient outcomes enables providers and payers to be on equal footing to create value-based payment contracts.
Suicide hotline shares data with for-profit spinoff, raising ethical questions
Crisis Text Line, a non-profit that uses big data and AI to provide text-based behavioral support, reportedly shares its anonymized text conversations with a for-profit spinoff that sells customer service software.
1-800 Contacts Announces New Company Focused on B2B Vision Technologies and Services
1-800 Contacts launches Luna Solutions, a new business that will offer third parties vision-focused services and technologies including telehealth and online prescriptions.
Cleveland Clinic Appoints Rohit Chandra, Ph.D., as Chief Digital Officer
Cleveland Clinic hires Rohit Chandra, PhD (Sunshine) to the newly created role of chief digital officer.
Politico reports that Crisis Text Line, a non-profit that uses big data and AI to provide text-based behavioral support, shares its anonymized text conversations with a for-profit spinoff that sells customer service software.
Experts question whether the data could be re-identified. They also note that its 50-paragraph disclosure form allows user data to be shared without further user consent, including with Facebook Messenger.
Crisis Text Line’s founder and former CEO has said that text conversations are predictive of self-harm – “numbs” and “sleeves” is 99% predictive of cutting, while chat terms “sex,” “oral,” and “Mormon” indicates that the user is questioning whether they are gay.
The service offers help for COVID-19, anxiety, eating disorders, depression, suicide, and self-harm. It triages texters based on suicidal risk from their first few messages, moving “code orange” texters to the top of the queue in reaching them in an average of 39 seconds.
From Undulation: “Re: DoD database. Three DoD doctors testified that data from its Defense Medical Epidemiology Database contains ICD codes that document massive side effects from COVID-19 vaccines. They cite numbers so extreme that I suspect they arise from database and/or EHR issues – as compared to five-year averages, an 300% increase in cancers, 269% increase in myocardial conditions, and a 1,000% increase in neurological conditions. I can’t find any fact checks on this.” I don’t know anything about DoD databases, but I’ll invite those who do to weigh in. The hearing was convened by Senator Ron Johnson (R-WI), whose chosen “second opinion” physician panelists are often labeled as misinformation spreaders.
About one-fourth of poll respondents who didn’t attend HIMSS21 plan to go to HIMSS22, while 80% of those who attended HIMSS21 will be back this year.
New poll to your right or here: What is your ideal way to make a health-related appointment? I read a New York Times article today about restaurants that have stopped answering phones, believing that it’s more efficient for customers to message them via Instagram or other means instead of taking up employee time to speak to them in real time (some have also decided that a web page is unnecessary). Reader comments were fascinating: some claimed ageism by restaurants that only want young customers for whom actually speaking to someone has become an inconvenience, many don’t like giving big tech sites even more clout, and others said that this change (along with delivery services, ghost kitchens, etc.) will kill the industry since cooking at home is better and cheaper once the social aspects have been eliminated. Some comments wisely questioned why restaurants can’t have a regularly updated, non-social media page that shows wait time since that’s often what people want to know. A wonderfully sarcastic reader opined, “Many folks nowadays cannot handle phone calls because it requires immediate listening, thinking, and responding skills. Texting, email and app driven activities provide a buffer for the slower witted and conformist lot.” Anyway, my take is that the market will sort itself out it always does, and a restaurant that misjudges customer preferences will either reverse course or close. Ditto patient scheduling, at least to the extent that the healthcare market is actually competitive.
Home tech tip: Mrs. HIStalk wanted to stream a movie from the 2022 Sundance Film Festival and bought a ticket, but Roku’s Online Festival Screenings app geoblocked us for some reason. Ten seconds of Googling alerted me that Roku devices now support AirPlay, which I didn’t know, so we streamed perfectly from her IPad to the Roku and TV.
Welcome to new HIStalk Platinum Sponsor Nym Health. The New York City-based company translates clinical language into accurate, compliant medical billing codes within seconds, automating revenue cycle management for healthcare providers. Combining computational linguistics and clinical intelligence, Nym’s autonomous medical coding platform is reducing costs and improving payment cycles for healthcare providers across the United States. Along with over 96% accuracy, Nym delivers comprehensive, audit-ready, traceable codes for full transparency. The Nym platform’s clinical language understanding engine processes over three million charts annually in more than 90 emergency department and urgent care settings. Thanks to Nym Health for supporting HIStalk.
I found this YouTube interview with Nym Health founder and CEO Amihai Neiderman, who explains the company’s technological approach to medical coding.
Eric Rosow reminded me in our conversation about the amazing vision of medical records pioneer Larry Weed, MD, which was well captured in his 1971 grand rounds presentation at Emory University, where he spoke eloquently without using notes. I was so taken by re-watching the primitive video recording that I transcribed the whole 53 minutes’ worth for posterity. For those who find a fascinating but long read daunting, here are some quotes, which were so far-reaching that whiz-bang app developers and freshly graduated medical students should still be inspired from them today.
February 9 (Wednesday) 1 ET. “2022 – Industry Predictions and Medicomp Roadmap.” Sponsor: Medicomp Systems. Presenters: David Lareau, CEO, Medicomp Systems; Jay Anders, MD, chief medical officer, Medicomp Systems; Dan Gainer, CTO, Medicomp Systems. The presenters will provide an update on the health IT industry and a review of the company’s milestones and insights that it gained over the past two years. Topics will include Cures Act implications, interoperability, AI, ambient listening, telehealth-first primary care, chronic care management, and new Quippe functionality and roadmap.
Previous webinars are on our YouTube channel. Contact Lorre to present your own.
Cleveland Clinic hires Rohit Chandra, PhD (Sunshine) to the newly created role of chief digital officer.
Patient payments and engagement platform vendor Millennia names Ankit Sharma, MBA (NThrive) as chief data and analytics officer.
The New York Times says the government of China is using its digital COVID-19 pass as a “potent techno-authoritarian tool” to control its citizens – tracking them, restricting their movements, and locating fugitives and dissenters. The government was already tracking people by cell phone, but the app also allows them to control travel by using unspecified criteria to change the app’s health code from green to yellow.
The US Consulate issues a “health alert” that a hospital in Los Cabos, Mexico preys on Americans patients by demanding upfront payments, overcharging them, and refusing to release their medical records. Mexican Consulate, you know what to do.
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I was so moved by this remarkable presentation that I took several hours to transcribe it. The presentation – delivered without notes by Larry Weed, MD at Emory University’s medical grand rounds in 1971 while referring to a chart he borrowed from its clinic– is as valid now, maybe more so, than it was 50-plus years ago. Thanks to VisualDx and its CEO Art Papier, MD, who was a medical student of Weed’s, for posting the video on YouTube.
Lawrence Weed, MD was a professor of medicine and pharmacology at Yale in the 1950s when he developed the concept of the problem-oriented medical record and the universally used SOAP note (subjective, objective, assessment, plan) for documenting patient care, which he incorporated into an electronic system. His dry humor comes through as he addressed his white-coated audience in Atlanta, much as it did in a JAMIA oral history where he described telling a surgeon who bristled at the idea of a computer adding value to his experience and intuition, “I’m not saying that you don’t have intuitive feelings. What I’m suggesting is that they may be worthless.”
Larry Weed died in 2017 at 93.
This is a long transcript of the nearly hour-long presentation, but I guarantee it’s worth reading.
It’s good for me to be here. I don’t know whether when I’m done you’ll think it’s good that I was here. But I can be a real hit-and-run driver. I don’t have to stay here, and if I’m lucky, I won’t get sick in Atlanta, because once you antagonize somebody and then you get sick in front of them, you’re never quite sure whether you’re safe or not. But from what TV says, you shouldn’t get sick in America anyway.
What I’d like to do is go at this problem, not from the point of view of the record. We really aren’t taking care of records — we take care of people. We’re trying to get across the idea that this record cannot be separated from the caring of that patient. This is not the practice of medicine over here and and the record over here. This is the practice of medicine. It’s intertwined with it. It determines what you do in the long run. You’re a victim of it, or you’re a triumph because of it. The human mind simply cannot carry all the information about all the patients in the practice without error. And so the record becomes part of your practice.
When you hear someone say, “I know lots of good practitioners [unintelligible] surgeon. He doesn’t keep any records at all.” How do you know he’s so good? Because he talks fast? Because he operates fast? Then we have to see the record. How many gastrectomies has he done? How many haven’t had infections? What do the wounds look like? How many dumping syndromes? How many have died? How many got infections?
Without a record, we’re not going to believe him. It’s like asking somebody his golf score three years ago without it written down. It’ll always come out better than it actually was.
We’ve got to look at the record. If this represents practice, you’d walk into a place like this and say, “I’d like to see how medicine is doing here. People say it’s a very good place or a very poor place.” How do you know?
Let’s see a patient’s problems. I picked this [chart] out of your clinic this morning. If you tell me what the problem is and I have a few minutes, I’ll either know myself or I’ll go to books or I’ll go to experts. We’ll say, “That’s pretty good standards for that problem.” But I’d have to know the problem well.
The first sheet is a little sheet here that says Oakland the Avenue or something. Then, phenobarbital addiction. Impression: probable addiction. Then a scribble here. Then there’s a blue sheet. I keep leafing through all this stuff. Then there’s an extra report — normal brain scan. Now they really didn’t do that for phenobarbital addiction, I don’t think. I’m leafing through this and I say, geez, I’d like to know where the problems are. You’d say, “Come on now. Dr. Weed. Pull yourself together. Let’s not try to make a big thing out of this record business just because you happen to be interested in records.”
You know, I’m interested in nucleic acid chemistry. I’ve been a biochemist a lot longer than I’ve been fussing around in clinical medicine. It’s not that I’m so interested in records. I’m interested in medicine. I had to use these to find out what was going on, and it’s got me absolutely climbing the wall. I could set it aside like I used to and say, “Never mind the record. I’ll tell you all I know about pyelonephritis.” But that doesn’t have anything to do with her. That’s Grand Rounds on me. That isn’t what you’ve come for.
So I’d say, “I’d like to know the problems.” You say, “They’re at the end of the workup. Find the first workup and you’ll find the problems.” So I come to here and I read through this impression: CVA. Number Two, extreme anxiety neurosis. Was that all the problems? All right, that’s all the problems. We can see how you diagnosed it and what you did for it. We’ll see if that’s good care for CVA.
I’m combing through here and it says blood pressure 180 over 98. Thorazine. They’re giving the Thorazine for a stroke? No, they’re giving that for the anxiety, maybe, I’m not quite sure. Then what’s all this SSKI? Then here is LE preps times three. For anxiety, or a stroke? Then x-rays of the left hip and the pelvis. Now you might say, “Don’t get excited. She probably fell out of bed.” Did she? I don’t know. Urinary tract infection. Honest to God, now they’re x-raying the left shoulder and the left hand next. Next impression, same patient — chronic obstructive lung disease. Personality disorder.
Then I go to the lab sheets, and you know what I see? PBIs, BUNs, serum sodiums.There’s a whole bunch of electrolytes in a row. Now you don’t do serum sodiums and all those electrolytes every day for a stroke. You don’t do them for anxiety. There must be another problem.
Now I can’t audit it. I don’t know. I don’t know whether you’re giving good care to the problem. I don’t even know whether you’re finding all the problems. If Problem Number One is hypertension and Problem Number Five is depression and you’re giving amitriptyline for Problem Number Five, the depression, that’s all right in itself. But that antagonizes guanethidine, and if you stop the amitriptyline and then they up the dose of the guanethidine, she has shock, hits her head on the bathtub, and she comes in here for a subdural hematoma, that’s your fault. But I can’t find it because it’s too hard to interpret this.
You can’t look at the management of a single problem without knowing the context. What are all the problems? Yes, she should have the hip pin, but not today, because Number One is heart failure. Yes, she should have fluids restricted, but Number Three is azotemia. Yes, she should have lots of fluids. It’s tough. It’s tough, and you shouldn’t have to spend a second finding what are all the problems.
Now what kind of a record have we got here? We’ve got a source-oriented record. It’s not a problem-oriented record. What I mean by that is this. In a source-oriented record, you put all the lab data together. You put all the x-rays together. You put all the temperature sheets together. You’ve got all the nurse’s notes together. You have all the doctor’s notes together. I say, “I’d like to know what you’re doing for the lady’s ear.” Well, there’s the temperature. Then I read the notes about the doctors and the progress notes. If you read some of these progress notes, doing well, home tomorrow. Phenobarb. Acute arthritis. Shoulder swollen. ECS 600 milligrams. RTL. ABC XYZ . It flows. It’s a single paragraph. The elbow, the urinary tract. It’s a series of things.
That’s the doctor, then you have the white counts and the serum sodiums and the urines together. Then you have the x-ray of the ear with the x-ray of the chest with the x-ray of the hip. I say, what are you doing that for? Why do you put the x-ray of the ear with the x-ray of the hip? What’s the ear got to do with the hip? Well, nothing, but we like to put those together. Why did you have all those ear cultures with those urine cultures? Is she urinating in her ear? What are you doing that for?
When people source-orient data, you appear very unscientific. But it’s even worse than the appearance. It’s the very essence of the practice of medicine. This is not an idle discussion of little technical bookkeeping details. The practice of medicine is the way you handle data and think with it. The way you handle it determines the way you think. Once you get over a period of time with multiple variables, the very structure of the data determines the quality of the output. This is what’s so hard for medicine to accept. They can’t say things like, “I know lots of good doctors don’t keep good records.” They can’t be separated that way.
You might say, you could figure out what’s wrong with that ear if you wanted to. You could sit down and read the whole record. With 200 million people, to get quality, I might spend three hours. But even then, I couldn’t do. It it would be impossible because I would be guessing. I’d come to the order sheet. This order sheet has all these orders, and I’d see penicillin on it. I wouldn’t be sure whether that’s the urinary tract infection, the pneumonia, or the ear. It doesn’t say. I see brain scan. I could guess that maybe that’s for the stroke, or I don’t know, or maybe he’s worried about a subdural or maybe he’s worried about a tumor. I don’t know, I’m guessing.
Then you might say, why don’t you call up the doctor to ask him? I’ll say, but that note was two months ago. You can’t be serious. You don’t say to a teller in a bank, “Do you remember Mr. Jones who came in two weeks ago? How much money did he put on the shelf?” If she answered you, you’d think she were crazy. If I had a technician read the spectrophotometer on Wednesday and write the numbers in the notebook on Thursday, I would fire her and I would get complete support in a basic science faculty. But in a medical faculty, writing discharge summaries three weeks later? Operative notes, preoperative notes after the operation? Somebody writes all his progress notes on Sunday morning? That’s fiction, it’s not science. Better that you not write anything at all than something that’s not absolutely reliable.
A source-oriented record is essentially useless from the point of view of a rigorous audit. And mind you, if you can’t audit a thing for quality, it means you do not have the means by which to produce quality. They’re inextricably entwined. If you can’t evaluate what you’re doing, then there’s a very serious possibility that you do not know what you’re doing, and that you’ve never defined your goal. That’s true in medicine. We have not.
You hear clinicians say, “Good clinicians always problem-orient their records.” Oh no they haven’t. No, they haven’t.
Let’s look at the four phases of medical action. This is the database. That’s the first phase of medical action. After you get some information, you’re going to formulate the problems, so you’re going to make a problem list. After you’ve got a problem list, you’re going to have a plan for each. Then you should follow each, and those should be titled and numbered progress notes.
You say, that’s what good clinicians have always done. They’ve done a history and a physical and lab work. That’s what the database is. Then they’ve made a list of impressions. We call it impressions, he called it problems, no difference there. Then we had a plan. We wrote in the order book, then we wrote progress notes. What’s so new about this?
Let’s take each one separately. Let’s take that that database. Was that ever defined? You know that that problem list is determined by that database. If all you know is her name, she doesn’t have any problems. If you know a name and her blood pressure, you may have one. If you know a name and her blood pressure and do a pelvic, you may have two. I would walk in here and I’d say, what’s the guaranteed database for these patients? The intern does a history and physical. You know what that means. Some ask five allergy questions, some ask 55. Some ask five if they have one admission, they ask one if they have five admissions, and they have none if they have seven admissions.
So the problem list is determined by where he trained, what he’s interested in, how many people came in last night, what the professor asked for, we have a rheumatologist for the attending. That’s not the way to run a shop. If you want a guaranteed list of problems and deal with the problems in context, you’d better define the database. You should get it every time. If you can’t get a complete database on people that have nails in their foot, you say fine, for these complaints like a nail in the foot, a broken arm, a person with a penile drip or gonorrhea, or something in his eye, we get what we call a mini-database. We do not get the whole database, but we give episodic care, but if you have a nail in the foot, we’ll ask these three questions, we’ll feel for your lymph nodes in your groin or something, we always give the TAP.
We do that much, but for comprehensive care, for someone with hypertension or weight loss or headaches, we do this. We have branching logic questions. We always do this on physical we get for this age groups. We get this lab work for the 40-year-old. We will get triglycerides and such and such. X-rays are done with this frequency. Paps are done in this frequency. People would say, we wouldn’t have time to do all that. Well, then get somebody else to do it. You’ve got to set the goal and then stick to it, and if you don’t have time to do it, get paramedical people to do it. They’ll do it better anyway and they’ll write it up so you can read it.
For instance in our clinics, as I was telling the the house officers this morning, “We don’t have time. It’s awful busy in the clinic. We don’t have time to get pelvics.” They have an excuse for everything. So what did I do? When they came in the front door, when they register, we have their age, they’re female, they’d go to the fifth floor, we’d trained nurses. They did the pelvic, the rectal, the belly exam, the breast exam, the thyroid exam. It was done in an organized way, checked off, they were checked out by the professor of OB/GYN.
You know as well as I do that they found much more than was being found in the medical clinic. In the medical clinic, they either didn’t get a pelvic, and half the time the fellows that did, they might as well been sticking their fingers out the window. You know that as well as I do. They were never cleared in an organized way on these problems, whereas when we taught the nurses, we ran them through 50, we checked them out in a systematic way – yes, she’s competent. We took no risks on box number one, getting a database. You use computers with branching logic questions. They can take them home. You use Mark-10 sheets. You can use interviewers, take these things and put them through a Selectric typewriter, through the business office computer, do whatever you have to do, but get the database and get it every time.
We found that with a questionnaire that had 32 questions, we got the vital signs, and we did it with paramedical personnel, it took between nine and 11 minutes. We found that the doctors were missing an average of 5.2 problems per patient, and some of them were quite serious. They were seeing in the patients what they wanted to see. They played Sherlock Holmes too early. They would ask one question and the next question was being determined by the first question, because that’s the way they were brought up in a CPC sort of an atmosphere. What do you think up next, doctor? Let’s put two men on the chess board. Move one and we will decide where to put the others on. Oh no you won’t, you’ll put them all on, we’ll look at the rules, and then we shall start to play.
It’s very arbitrary how much data you get before you start to think. Under pressure, if you let people get data in a Sherlock Holmes way, they get so they get less and less data, have more and more intuition, draw conclusions more and more prematurely, and get people into more and more trouble. Always saying they don’t have time.
In nine minutes, you can find out a fantastic amount of information if you will just do it. Just do it. Don’t think, just do it. People say, yeah, but it’s so arbitrary. I know it’s arbitrary, people. Everything is arbitrary. A football field is arbitrary. It could be 150 yards long, it could be 75, it could be 100. But if you do not draw the line, you will not play the game and you won’t how you’re doing.
Suppose I’m running down the field and I fall down on the 15-yard line. I get up and say, that’s a touchdown. By whose definition? My own — I’m tired today. That sounds absolutely ridiculous, but that’s the way we practice medicine. Best ENT man in town — that’s his database, here and here [gestures to ear and mouth]. You say, he never gets in trouble. Oh, maybe once out of 100 times. He took that lady up, took her larynx out, she happened to be in bad heart failure. She died of something, he didn’t know she was hypertensive. You realize, I’m sure, that the Lord and the chiropractors can get 85% of these people better. The only reason you run these fantastic establishments is to get that other 10%. The only reason you have a professor of medicine is to pick up that final 2%.
We know it’s arbitrary, but you must define it, and once it’s defined, once you realize when you fall down on the 15-yard line and say “that’s a touchdown,” I say no, you don’t get the score, you’ve got to over that line. Well geez, don’t I get some credit? I’ve been fighting all the way down this field for an hour, they battered me up tonight, I’m exhausted, and they were awful big guys that were on top. This guy down there the at the medical clinic, he doesn’t realize how big this is. I’m sorry, buddy, you don’t go over the line, you don’t get credit.
Once that’s very clear in your mind and the object is to get the data, you’ll figure out ways. You’ll learn to think of forward passes and you go home and study up new plays, because we’re not going to change the game just because you’re tired. You begin to improve this profession, but this profession truly is a cottage industry, everybody wandering around defining his own game. And when you’re allowed to define your own game, you’re a fool not to define it in a way that you’re always the victor. Of course the medical profession gets the appearance of being arrogant and independent. Anybody that’s been allowed to define his own game all his life, that’s conducive to arrogance. He never has a defeat. He’s always got a way out. She was too sick. She went sour. What does that mean?
That’s the first phase. Look at the second phase here. You’re going to get a problem list from the database. You say, we’ve always made a list of impressions. Did we ever do that any better than in the database? In the first place, we use the word “impression.” That was a terrible thing to do in the first place. If you use the word impression, or what you think, you then have to have the person who wrote the chart with you when you interpret the chart, because what he’s thinking is part of it. I’m not interested in what the impression is. I’m interested what you know to be the problem, and no ambiguity about it.
Occasionally people say, I don’t know, geez, Larry, everything’s black and white to you. You just put a number on things. I don’t know whether it’s rheumatic heart disease or a cardiomyopathy. I said, what do you know? What do you know? Do you know the diagnosis? No. Do you know a physiological finding, like heart failure? Yeah, I know she’s in heart failure. Then that’s your problem, Doctor, that’s your problem. If you knew it was rheumatic heart disease, put it, that’s your problem. We might say, if you want me to be absolutely honest, I don’t even know that. Well, what do you know for sure? Is it a symptom or a physical finding? Yes, I’m very sure she’s short of breath. I can guarantee you, Doctor, if I take you in the room there, you may not agree it’s rheumatic heart disease and you may not agree it’s heart failure, but you’ll have to admit she’s very short of breath. I don’ t know whether it’s chronic obstructive lung disease or cardiac failure. She may have piece of corn caught in her trachea, for all I know. Well, that’s the problem.
You might say, I picked up his chart he’s got, question mark, organic heart disease. I saw that in one of those clinic charts. I say, what’s the problem? He doesn’t remember, he had a lot of admissions last night – oh yeah, she’s that one with the funny cardiogram. Doctor, that was pretty risky. You never want to lose sight of the problem. If you hadn’t been here and I had to use that chart, I could spend an hour trying to find out what the problem was, and if I had to go through your laundry basket to find that EKG, that’s very risky. He says – this was a new intern – it seems logical to me, but you don’t honestly want me to put down Problem Number Four, funny looking EKG, now now do you? I haven’t yet had a course in cardiology. I just don’t know anything. I just don’t think we can be expected to know everything.
I said, yes, Doctor, if that’s the level at which you understand the problem, put it down that way. If that’s the level at which your care is being given, there’s nothing to be ashamed of about that. There’s no reason why you should know all about cardiology. An ophthalmologist doesn’t, and you don’t know all about ophthalmology, either. The neurologist doesn’t know all about endocrine disease. All you have to do is be honest. Then I’ll say to you, what’s funny about it? The dumbest person, instead of putting down “funny cardiogram,” will take one second say, what’s funny about it? Look at the reading — those are U waves that shouldn’t be there. So that problem is Number Three, U waves in cardiogram.
You can call up anybody in seconds in the middle of the night and say, “would you see this patient?” What’s the problem? You read off the problem say, “Number Three is U waves.” He’ll say, get a potassium, do this, I’ll be in. After 30 seconds, he’s with you. But if you say going out the door, “I got a lady that I think has a little heart disease, would you see her? I’m going to see if I can operate tomorrow.” You can go upstairs and pick up this record you can be glommering through it for half an hour and still not be sure what’s bothering you. What you usually do is throw it on the desk and say to the nurse, show me the patient. You wander down, look her over, and from your experience, you sort of think she’ll live through that operation. You hold your breath and clear her and that’s the end of it, usually. It should be much more precise than that. We haven’t defined problems. We’ve put down impressions.
Now what else about the problem is it wasn’t kept up to date. I stumbled over the fact of arthritis, LE preps, hip x-rays, PBI, CVAs. This lady has at least 10 problems. What happens when I stumble over it in this way? I’m scared to death there’s some that I’m missing. So then when I find a couple of important ones, then I panic, I go back, and now I’ve got to read every word, because they’re scattered in the middle of pages and the end of lab sheets. Whenever a new problem appears, it should go on that problem list, and that problem should sit on the front of the record and it should be absolutely up to date. We have to be ruthless with the doctor, not who does the right or wrong thing for heart failure – only God is right or wrong for some of these problems, it’s very confusing — but you have to be ruthless with him if he does not keep the problem list up to date so that anyone in seconds can be in context and make intelligent decisions.
Over and over again, I didn’t know, postoperative, everything’s going wrong. Then we discover the old record that she’s had hypothyroidism and no one gave her the thyroid pills and we got mixed edema coma up on the operating table. That’s inexcusable, and it happens in every hospital in this country. Lymph nodes didn’t get cultured. I didn’t know. I didn’t know. I couldn’t get time to go to the operating room doctor. It can’t be you that takes care of a patient alone. When you see a head resident running around at night to see all the patients that came in, that’s fraudulent. He can’t possibly be the intern for that many people.
He either has a system he trusts or he’s going to lose. When he’s the most most ruthless were the people under him is when they violate the system, because the people are in the hands of the system.
When someone says “I take care of that patient. I’m her doctor.” that’s fraudulent. No one points to a Pontiac and says, “I made that car.” A system makes that car. And even in the pre-Flexner days, no one could take out cataracts, handle porphyria, diabetic acidosis, perforated ulcers, depression. No one ever did all those as well as they could be done. Of course we want specialization, and if you have a gall bladder problem that’s really tough, of course you want Cattell to sit up there and do it at the Lahey Clinic. He’s done thousands of them. He was magnificent. You want that if someone takes out your mother’s cataracts. You want the feeling that he’s done hundreds of them. He does them magnificently with minimal chance of failure. But yet if he’s that good and focuses, will he be able to encompass everything? No, he will not.
So you want people to be part of the system. You don’t want a family practice program where you teach them to be superficial. A system builds automobiles and it’s going to take care of people, and if we don’t recognize that simple fact, then there’s going to be an awful lot of people that are not going to get cared of and there will be a 100,000 people in the middle of Chicago floating around Cook County getting less than adequate care. It’s like Henry Ford saying, “I personally am going to make an automobile for everyone the population. I don’t believe in systems and assembly lines. I’d rather have my personal touch on it.” He’ll make an automobile for two or three people a year. The other 200 million will have none, and that is the basis for a revolution. This is the basis for a system. The record has to be it. You can write a check in Atlanta on a New York bank, why? Because there’s a system, and it’s known throughout. But you get a coronary in Atlanta and your records are in Chicago, just try to find things out in the first 24 hours, because even if you call up and they got it out of the record, the girl in the record room is in the same position I was. “What did you want to know, Doctor?” and there she is. You probably wouldn’t be able to get her on the phone, but if you did, you’re just wasting your money. She should be able to read off that problem list just like that.
What about the next phase of medical action, where we talk about the plans for each problem? What have we done there? We’ve taken an order sheet and just scribbled orders – penicillin, BUN, side rails, phenobarb, serum sodium daily, IVP tomorrow. You say, do you think that those sodiums every day are necessary? I don’t know, I don’t know what you did them for. I suppose if you had some fancy endocrine disorder, aldosteronism or something you were fooling with, that might be sensible. If it’s for flat feet, that’s a waste of money. No one should ever be able to write an order without coupling it with a problem.
When you write plans, you have to think of them in three phases. You put down Problem Number One, hypertension. You’ll find you get a whole new spirit out of your nurses once you start dealing with problem-oriented records. They become part of the team. They know everything they’re doing. They know how one doctor does it differently. They ask why. They become more and more sophisticated. Before, they were asked to go blindly. They went down and gave the penicillin. They didn’t know what it was for. They couldn’t see if you’re being consistent, whether you agree with other infectious disease people.
It was like walking into a room and people were throwing darts, and you say, where’s the target? Wherever the dart lands. This is the arrogance with with some doctors treat nurses. It’s no fun for the nurse. If you have a target up there and I come in here throwing darts, anyone will stop for a minute to see if you hit it. It’s a challenge. It’s tough on you if you miss it all the time with that many people watching, but that’s what education is all about. You learn to improve after a while. Either that your you’ll stop publicly taking care of people, and that’s that’s an advantage too in some cases.
Under any problem, under A, what are you going to do first? This is where you get more information. This is why you should always think about plans for problems. For more information, for why. This is where your rule-outs go. I’m going to rule out unilateral kidney disease. How? Right there, I want the rule-out. Are you going to do it with a timed IVP or renogram or what are you going to do? Aldosteronism, and if so, you go do one serum potassium, then do five, you’re going to do with the dividing line going to be 3.8, 4.3, 2.2? High-salt diet, low-salt diet. Let’s precisely decide now before we spend your money.
When you see doctors on work rounds saying, “She had a little problem here, but you know, she was on a diuretic, I don’t think I’m going to worry too much about that,” that thinking should have been done before you drew it. When you see people thinking of what to do, how to do it, and how they’re going to interpret in 30 seconds at the end of a bed in a random fashion, it’s like a contractor saying, all these architect plans, let’s lay a few pipes here. The pipes of the john can’t come up in the fireplace. You can’t do that. Fortunately, as I say our house officers, you know now the sickest kidney is brighter than the brightest intern. I mean, it’ll it’ll sort your IVs no matter what you do.
But anyway, you’re going to put your rule-outs. You see I’ve taken those rule-outs away from the problem list. The problem should not have rule-outs, question marks, or probables. It should be a precise, reproducible statement of the problem at the level you can understand it and guarantee it, no matter how unsophisticated you have to get.
We’ve got to fix the system so that students are much more ashamed of being imprecise and dishonest than they are of being unsophisticated. They should never worry about whether they remember or whether they’re sophisticated. All they have to be ashamed of is that I miscommunicated. I overstated the case. I misstated the problem. As Bernanos says, the worst, the most corrupting of all lies, is to misstate the problem. Keep it pure, and then in your plans under more information, we’ll go your thinking and your logic. There’s your differential diagnosis. But don’t let it get mixed up with the problem until you can update your problem in a secure way.
I pick up charts and one I picked up today had infectious disease, question mark on a problem list. What does that mean? In our place, I picked one up the other day. It says Problem Number Five, rule out diabetes. I said, what’s the problem? He couldn’t remember whether it was the urinary tract stricture. Is she the one with polyneuropathy? He says, you don’t realize how busy this is. I said Doctor, never lose sight of the problems. I said, do you see what you would have done? You put “rule out diabetes.” You do glucose tolerance. The resident says, how’s that glucose tolerance? You say two hours was 115, fine, we cleared that up, she can go home.
Cleared it up? She never had it. You see, the problem is still vaginitis or neuropathy. Another plan was rule out diabetes, and when that’s normal, then what are you going to do next? You’ll find, if you do this rigorously, that over half the time, on half the problems, you will never resolve it. You’ve got to learn what Whitehead talks about, this capacity for a sustained muddle-headedness, a tolerance of ambiguity. Pavlov said you must teach a graduate student gradualness. He must never be forced to overstate his position, misstate his problem. Good medicine is a careful, rigorous inching your way towards a more and more secure position. A final diagnosis is a myth. There are never two cases of lupus the same. There are no absolute final criteria. You must define them, but recognize that it’s the evolution and the following of a patient that’s going to make the difference within these explicit definitions.
What’s B? What you’re going to do to treat?
Never mix what you’re going to do to treat with what you’re going to do to get more information now. You say, we never would do that, but yes you do. I’ll see in treatment when I pull a chart and separate and I see cholorothiazide here and they were getting urine sodiums for this aldosteronism. As I separate data, oh my God, you see that what they were doing is that they were getting more information on what they did than on what they had. We do that all the time. We do so much to a patient. We give them so many drugs, and so many procedures, and so much psychiatric confusion that when we do our tests, it’s really more information on what we’ve done to her than what the original problem was. The intern gets her in here, she’s got all this diarrhea, and the next thing you know he’s doing stool analysis on barium.
Let’s see under any plan what you’re going to do to tell the patient. In no place in American records do we have an organized approach to what we’re going to do tell the patient. Under that hypertension, did you tell her it was serious, or not serious? How you’re going to study it, or whether you’re not going to study?
All right, now let me quickly get from the plan to the progress notes. Never in American medicine have we had highly structured progress notes in a problem-oriented way, where we had a complete problem list and we numbered every problem progress note with respect to the problem. We’re in this box for now. Never write “doing well.” What does that mean? She’s got arthritis, heart failure, azotemia, broken hip, and ear infection. You put “doing well.”
What you mean is I’m a cardiologist, they asked me to look at it, I did, we said digitalize her, I came in today, I listened, the rales are going away, the edema is less, she lost a few pounds, gallop’s gone away, rhythm’s a little slower, rate’s a little slower, I think she’s doing well. I didn’t know she had glaucoma, these urinary tract infections annoy me, and I never worked up a broken hip in 20 years anyway. That’s what he means. Someone said to James Thurber, how’s your wife? In what way?
When you put the problem, you put 1. Hypertension, and then always write symptomatically and objectively your quick interpretation and your plan for the next step. Always give the patient’s point of view first, then what objective data you have, and where you going to go. You’re taking each problem in depth. Then you look back at the complete problem list and look at them in context. What does this mean? It means you can write a plan for azotemia, you can read Strauss’s book, or you can write one for heart failure [unintelligible], and you can know broken hips, but you can’t write a book for Mrs. Jones, who’s got this much heart failure, that much azotemia, and a broken hip. She’s absolutely unique. Eighty-eight keys on the piano and a million symphonies.
There is no absolute treatment for anything. You can lay out your plan explicitly, set up your flow sheet, and then look at it make a move, like in the chess game. Watch nature’s move, then make another move. You’re a guidance system. If you know those satellites, they get up there and they land here on Wednesday or Thursday by this battleship. What are they doing? They’re taking their position every instant with four computers on this system. They keep readjusting their course.The shape of the path is not precisely known until the input stops it. It doesn’t need to be known, but you have to take your parameters of guidance, how often to look, and you readjust.
When you go from Atlanta to Seattle, you never go the same way twice. Sometimes you go to the northern route, the southern route, and even if you try to go the same way twice, you could not. There’s a red light here, before there was a green light. The bridge is washed out in Chicago. You read detour signs, you go around. There’s a tornado in Montana. You meet a nice girl in, you know, Oregon. You call up your family, you’re going to be a couple days late. The car breaks down.
But you know all the principles — red lights, green lines, detour signs, automobile maps — and once you believe that boy has learned to go from Cleveland to Seattle, you don’t give them a special course now to go from Cleveland to Hong Kong and Cleveland to San Francisco. You expect that he’ll choose parameters, the same physiological ones over and over again, whether you having a fluid balance problem from heart failure or a bad burn or an intestinal obstruction or diabetic acidosis. You’re going to make a volume decision and a free water decision and an acid-base decision and a potassium decision. It’s the same heart and kidneys. The agent that threw you off is a little bit different, but the commonality of it all has got to be seen by the student or he’ll memorize and memorize and memorize and then collapse or just distort.
In biochemistry, we get so upset with those flip-flop circuits when we do the counting. You wouldn’t mind so much if they worked or didn’t work at all, but the trouble is they have worked, and they sort of stopped counting in the middle the night, but you wouldn’t know it and you’d report something that was absolutely ridiculous.
That’s the way interns and residents and doctors are. If they worked perfectly, it’d be one thing, or if they didn’t work at all. But we half work. We half guess. We half understand. We half know. But we’re never uncertain about going to the order book and writing a drug. No matter how busy a doctor is, I’ve yet to have a doctor say to me, I was so busy I didn’t have time to order anything. He’s always so busy he didn’t have time to find out anything, but he’s always got time to order something.
What I’m saying is that a doctor has to be a guidance system. He is not an oracle that knows answers. Once he accepts the concept of being a guidance system, then he knows that the data system is the basis from which all his work must take place. Then the record suddenly becomes an unbelievably important document in education, in care, and in research.
But as long as we were a profession that thought we could rest on the memory, and it what you know makes a difference instead of what you do, and as long as we thought of doctors as oracles that know answers instead of guidance systems in uncertain situations, we were willing to let the record in American medicine fall to this level. Now the computer people move in, and the Medicare people move in, and the non-medical people move, in they can hardly believe what they see. There is a crisis of major proportions.
The first hospital I went where we decided to stop source-oriented records for problem-oriented records, the first thing I did was we canceled all the conferences and all the rounding that wasn’t directed to specific problems. From 6:00 in the morning till midnight seven days a week, we got these things so the database was defined, the problem lists were up to date, the plans were in order, and there were progress notes at the right frequency.
It’s just like a fifth-year graduate student in biochemistry. When it gets down to the time and he’s got to get out, he stops going to hear the Nobel Prize winners, he stops all in these conferences, he stops running around, he isn’t going on with dinner with his wife, he isn’t chatting in the hallway. He’s doing one thing — he’s in that laboratory and he’s working on that thesis. This [the chart] is a doctor’s thesis. He may get an A in all his courses, but if his thesis is no good, it’s not creative, the work was no good and it’s unreliable, all those A’s in advanced calculus and biochemistry mean nothing.
The same way with us. If this is not interpreted or auditable and the quality is not good, then all the rounds, all the specialization, all the NIH, and all the hierarchy mean nothing. Mean nothing. You might say, but don’t you think we should have research? Yes, I think we should have research, but this is research. Every patient’s different. We don’t have to run away from the bedside to be profound and to be unbelievable scientists.
I worked a long time in nucleic acid chemistry and I can tell you from my own experience that there is nothing that taxes you intellectually or taxes your sense of science and philosophy the way this situation does. Basic scientists who’ve been allowed to focus on one or two problems and keep their data in a separate notebook and come in from eight to five and shut off the incubator when they want to go away, they have no concept of what it is to have five problems per patient, 30 patients on the ward, 150 problems running simultaneously.
They never taught a data system for that. But because it’s so difficult and because it’s just in its infancy of what we could do doesn’t mean it’s unscientific or that it’s unsophisticated, and when someone says, geez isn’t it more sophisticated to get new knowledge or go to the NIH and work with Nierenberg and find a new nucleotide or work out the code, those are pieces. They’re sophisticated, they’re worthwhile. I don’t begrudge him his Nobel Prize. I’m glad to have these things happen. I worked on these I got more more money and more job offers and more professorships offered from biochemistry than I ever did out of clinical medicine, and I don’t begrudge people. It was very useful to me at the time.
But to say that to sit up in the attic carving the chess men and writing the rules, as the universities have done for 2,000 years, to say that’s more sophisticated than playing the game with those men, that’s ridiculous. It’s unbelievably sophisticated to take those men and play the game. You don’t need to stop making the chess men. We don’t need to burn down the NIH or stop the research laboratories to go on to this more sophisticated state of playing. The students should never think of that clinic with hundreds of patients and all this confusion and how to get the database. That’s a very sophisticated problem in systems analysis, in efficiency. In order to decide if you’ve got 100 patients to see there this afternoon and you’ve got to get the database that will yield the most, which problems do you want? You’ve got to know a great deal about the science of medicine. If we’re after heart failure, is best to grab a venous pressure, add five questions on the history? What is the highest yield? If it’s hyperthyroidism, should we talk to her about diarrhea, weight loss? Should we grab PBIs? If there are 10 things you could do, which have the highest yield? What do they really know about hyperthyroidism anyway? Let’s turn it to play this game.
You’ll find that they haven’t really thought about it very rigorously. They just have the pieces. They’re going to put them together tomorrow, but tomorrow never came. Pusey said, but isn’t the university to discover new knowledge? Of course the university is to discover new knowledge. But the new knowledge we need now, and it’s most difficult and most sophisticated, is how to use knowledge. That’s that’s a very profound thing to do. This [the chart] is the physical representation of doing or not doing it. It runs head-on with society. It’s very easy to go down to the molecular level and work on trinucleotides or triphosphates or anything else, or to go out in outer space where only your methods can measure how badly off you are. In biochemistry, we used to say we have the microsomes and the mitochondria, That’s a pure amount of mitochondrial prep, we’d say. We thought it was until the methods got better and we could see it with an electron microscope and see it full of junk, microsomes, all sorts of junk in there.
In other words, the purity of these isolated systems is only good insofar as your capacity to find the faults, whereas when you work in that clinic, it’s at the macro level. It’s not so distant and so macro that you can’t see it. It’s not so micro that you can’t see it. It’s patients moving around. It’s like a big cell here. Instead of mitochondria, there’s patients and doctors and pharmacies. There’s a nucleus. It can be centrifuged and separated, put together and studied, but the reason we don’t like to do it is because your faults are so obvious. Your mistakes are so obvious. The lack of purity of your approach is so obvious. You can’t stand it, so you say it’s unimportant or it’s not scientific or that’s not why I came into medicine. We’re cowards. It’s perfectly clear that’s what the problem is. Society is unreasonable. It’s frustrating. It’s irrational. The cell was, too. The centrifuge was, too. Those mitochondria were, they weren’t pure prep. The only difference was is they couldn’t talk back and we couldn’t see it and we didn’t devise methods to see how badly off we were all right now.
Let me make one closing remark about what this has all got to do with the art of medicine. Where is the art of medicine going to go with all this if you if you have lists and numbers, for art is style, structure, form, discipline. It’s Andrew Wyeth making Jamie Wyeth do the painting 50 times until it’s right. Unbelievable discipline about technique. He made that boy tear up a painting 100 times. It’s George Szell, if you have ever watched him with that orchestra. The same passage 30 times until it was perfect, and no violinist stood up and said, this is interfering with my art. Nor did Bach say, three beats in every measure? That interferes with my creativity. No, art is Hemingway, three weeks on a single paragraph. It’s Bach recording in detail everything he did a couple hundred years ago so we can hear it today.
It’s not a scribble in the middle of the night. It’s not saying, “I took good care of her,” leaving absolutely no trail for us to ever find out whether you did or did not. We debase the word art itself when we call what we’ve been doing art. And it’s not science. We have to be extremely careful when we defend what we’re doing. We don’t reveal to others that we didn’t even get out of a liberal arts education, as Stravinsky says, that art is nothing more than placing limits and working against them rigorously, and if you refuse to place them and try to work within them but just flail about, you do not have art, you have chaos. That’s to a large extent what we’ve had.
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