Preventing Unintended Intraoperative Awareness

Intraoperative awareness, the condition that occurs when surgical patients under general anesthesia can recall sounds, events or even pain during their surgery, has been reported, but caution must be used when discussing this controversial trend. Anesthesiologists practicing in ambulatory surgery centers (ASCs) should be aware of this condition, as it is a reminder that patient safety and comfort is of utmost importance.

According to the Joint Commission, 48 percent of patients who experience awareness have it in the form of auditory recollections, 48 percent feel they cannot breathe and 28 percent experience pain. About half of patients experiencing intraoperative awareness end up suffering from mental distress following surgery.¹

“Unintended awareness is always an issue — and is something to be avoided — whenever and wherever general anesthesia is administered,” says Robert E. Johnstone, MD, vice president for professional affairs for the American Society of Anesthesiologists, and professor of anesthesiology at West Virginia University. “Unintended awareness appears to occur less often, though, in ambulatory surgery centers, perhaps because of the types of surgery done there. It’s been linked most closely with cardiac, obstetric and trauma surgery. It’s a rare occurrence, and ongoing studies as well as reports into the awareness data registry may clarify where and why it occurs.”

According to a paper, “Intraoperative Awareness in a Regional Medical System: A Review of Three Years’ Data,” published in the journal Anesthesiology in 2007, intraoperative awareness incidents may be as low as 1 in 14,000 surgeries.²Â Researchers reviewed data from more than 87,000 patients who underwent general anesthesia between 2002 and 2004 at facilities near Charlotte, N.C., including one ASC, an academic medical center and six community hospitals. Throughout the study, anesthesia was delivered by board-certified anesthesiologists and supervised certified registered nurse anesthetists. Brain function monitors were not used, and patients were interviewed twice during a 48-hour post-operative period under the qualifications of a modified Brice interview to determine awareness. The study concluded that “intraoperative awareness in patients undergoing general anesthesia is an infrequent but well-described adverse outcome. The reported incidence of this phenomenon is between 0.1 percent and 0.9 percent.”

While some clinicians say that more data is needed to fully understand the challenges of intraoperative awareness; many are glad the data has raised the profile of this issue. An alert issued by The Joint Commission notes, “Better understanding among healthcare professionals of this frightening phenomenon could reduce the risk of these events and assure appropriate support for patients when they do occur.” Another Joint Commission document, “Preventing and Managing the Impact of Anesthesia Awareness,” states that, “awareness is reported to be greater in patients in which the dose of general anesthetic must be smaller and carefully titrated to decrease significant side effects, for example, a patient who is hemodynamically unstable … Factors contributing to the risk of anesthesia awareness include the increasing use of intravenous (IV) delivery of anesthesia, as opposed to inhalation, and the premature lightening of anesthesia at the end of procedures to facilitate operating room (OR) turnover.”

Incidences of awareness occur once or twice per 1,000 surgeries performed under general anesthesia, according to the American Society of Anesthesiologists (ASA). Not all incidences of recall during medical procedures involving anesthesia are considered cases of awareness. Patients who receive sedation, local anesthesia, regional blocks, spinal or epidural anesthesia are expected to be somewhat awake or aware of their surroundings and have some recall of the procedure. In addition at the very end of a surgical procedure, the anesthetic is reduced so that patients can awaken and therefore, there may be some awareness during this period.

The risk for anesthesia awareness is higher for unstable patients or for patients undergoing high-risk surgeries such as trauma, cardiac surgery or emergency Caesarean sections. In these high-risk cases, using a deep anesthetic may not be in the best interest for patient’s safety.

“Regardless of statistics, even one case of anesthesia awareness is too many,” says Roger A. Moore, MD, president of the ASA. “The ASA continues to study the occurrence of awareness to find effective ways to prevent the condition. The entire surgical team must be vigilant before, during and after surgery to ensure the safety, comfort and recovery of each patient.”

Specific steps can be taken by physicians and patients to reduce the risk of awareness. Patients and anesthesiologists should meet prior to surgery to discuss anesthesia options as well as the patient’s surgical, anesthetic and medication history. It may be helpful for patients to have a friend or family member advocate with them for this discussion. It is during this visit that patients should discuss any anxiety or concerns about their procedure with the anesthesiologist including possible awareness.

“The ASA has developed numerous standards, guidelines and advisories that describe safe and best practices,” Johnstone says. “Anesthesiologists should always consider these in their anesthetic plans and practices. Patients can check that an anesthesiologist is directly involved with their anesthesia care, and should review their concerns with their anesthesiologist preoperatively. Arriving at an ASC with a list of medicines, allergies and pertinent medical information is also wise.”

Following surgery, patients who believe they may have experienced anesthesia awareness are encouraged to contact their anesthesiologist regarding their experience. The first step in overcoming the adverse emotional consequences of an intra-operative awareness experience is acknowledgement that it may have occurred.

Seeking greater understanding why awareness occurs, ASA has sponsored the development of The Anesthesia Awareness Database, a voluntary registry of patients who have experienced awareness.

The Anesthesia Awareness Database was developed to understand why anesthesia awareness occurs, to prevent future occurrences of awareness, and to help anesthesiologists and other healthcare professionals better understand and assist patients who experience awareness.

The Joint Commission’s recommendations to help prevent intraoperative awareness include:

• Identify patients who are at proportionately higher risk for an awareness experience, and discuss the risks with them prior to surgery
• Use available anesthesia monitoring techniques
• Properly maintain anesthesia equipment
• Educate clinical staff about anesthesia awareness and how to handle patients who have experienced it
• Conduct post-operative follow-ups with all anesthesia patients, including children
• Facilitate access to support systems for patients who are experiencing mental distress.

References

1. The Joint Commission. Preventing and managing the impact of anesthesia awareness. Issue 32. Oct. 2004.
2. Pollard R, Coyle J, et al. Intraoperative awareness in a regional medical system: a review of 3 years’ data clinical investigations. Anesthesiology. February 2007.

An Ineffective Autism Treatment and Other Health News

Trial Shows Autism Treatment Ineffective

The antidepressant Celexa, often prescribed for children with autism, doesn’t lessen the repetitive behaviors that are characteristic of the disorder, the Wall Street Journal reports. A government-funded study of 149 children with autism and similar disorders, published in Monday’s Archives of General Psychiatry, found participants who received Celexa had no more benefit than children who received a placebo. A good autism treatment should improve behavior significantly in more than 50 percent of kids, study author Lawrence Scahill told the Journal. Antidepressants, shown to be effective in children with obsessive-compulsive disorder who repeat behaviors, haven’t been thoroughly researched in children with autism. This study is the first to show the drugs do not help relieve repetitive behaviors of autism, which can include movement symptoms like rocking, swaying, or arm-flapping.

In April, U.S. News’s Nancy Shute reported on 4 promising autism treatments, from vitamin B12 to the Alzheimer’s drug Namenda. Research released a few months ago found a genetic link to autism; learn what that finding means for parents of autistic children.

Abortion Doctor’s Murder: a Threat to Access?

One of only three doctors in the country to perform abortions late into pregnancy was killed Sunday in his church. While killings of abortion providers are rare—this is the first in a decade—doctors who do abortions are frequently harassed and live in fear for their lives, writes U.S. News’s Deborah Kotz. The ostracism extends to doctors who perform abortions in only the first 12 weeks of pregnancy, Kotz found while interviewing gynecologists who were reluctant to speak on the record about whether women in this country are having a harder time gaining access to abortions. The safety and support of healthcare practitioners who provide them are critical if women are going to have access, she writes.

Some states have also made efforts to limit a woman’s access to abortion services. While states can’t outlaw abortion outright under Roe v. Wade, state legislators can make it more difficult for women to obtain abortions. Indiana, for example, has a bill pending that would require doctors who perform abortions to have admitting privileges at a hospital. Kotz gives a rundown of state abortion laws currently on the books.

Find out why abortion rates are falling and if you should consider stopping your birth control pills if you’re over 35.

Online Groups Help Parents Weigh Tough Treatment Choices

Networks of expert parents are as close as your computer, in online patient groups, U.S. News’s Nancy Shute reports. They offer wisdom and up-to-date medical information that can be invaluable to families facing tough treatment choices. “Amateur” medical informationisn’t clinically tested or peer reviewed, so it shouldn’t be considered a sole source, Shute writes, but it can serve as a guide to navigating the tsunami of information on Google and other search sites, as well as the recommendations that patients get from their doctors. Shute identifies 3 ways online patient groups can help, which include supplying additional information on alternative treatments. When different doctors give different advice on treatment, online parent groups may help weigh the options. Research on online patient groups finds that their greatest benefit lies in providing accurate information, rather than emotional support, Shute writes.

Here’s how a website can help you answer the question How much should you pay for medical care?

American Recovery & Reinvestment Act – Impact on Healthcare Providers

According to the Obama’s website, “Unrelenting health care costs are burdening business, state governments, and our economy. The American Reinvestment and Recovery Act will prevent health coverage loss and stabilize the system. It will make key investments now that will lower health spending in the long run. It is part of the Presidents’ commitment to make health care affordable for all Americans.”

Sounds great but how does this affect me as a healthcare provider?

One of the biggest impacts on Obama’s plan is on how clinical information will flow throughout our healthcare system, as well as how this information will be used by the government to monitor treatments. A $17.2 billion incentive is set up for Medicare and Medicaid providers, who implement a certified healthcare information technology (“HIT”) system “in a meaningful way”. It’s been estimated that physicians could earn from $40,000 to $60,000 in additional government payments (Medicare and Medicaid) over a 5 year period of time. On the other hand, hospitals could earn $2 million annually in incentives through this program. A “certified HIT” is one that provides clinical decisions to physicians through order entry and system queries. It must also be able to be integrated with other HIT systems for purposes of sharing such information. 

What does this mean for consumers? For one, patient privacy rights may be at risk, as everyone’s medical treatment data will be tracked electronically by the National Coordinator of Health Information Technology, a federally controlled IT System. While this may be helpful in minimizing errors, avoiding duplication of tests and improving data input efficiencies, the federal government will monitor treatments and physicians’ decisions in terms of patient care. The stated goal is “to reduce costs and ‘guide’ doctors’ decisions.” While privacy rules provide a power of attorney so a hospital can communicate with a doctors’ office, the impact has yet to be addressed in terms of protection of patient information with all such information available at the click of a button.

An alternative approach to our government needs to seriously consider is a Personal Medical Record (PMR). Unlike the newly proposed plan, PMR is maintained by the user (not a federally controlled IT System). Patients’ health information, family history, previous prescriptions or health conditions can be stored in a single record. No more filling out the same form over and over again regarding allergies, hospital stays, current prescriptions, etc. The fundamental aspect of PMR is that the patient decides who gets what information when. Yes, the patient, not our governemt, controls one’s healthcare informaiton.

The next couple years will be filled iwth much change and uncertainty. Change hopefully that will improve, not diminish a healthcare system that is second to none in the world.

If you would like to read our previous article, on this topic please read here

Callisto eye: A Revolution in Ophthalmic Information Systems

The successful medical equipment company, Carl Zeiss, is now offering a revolutionary product in Ophthalmic Information Technology named the Callisto eye. This information and documentation system has been developed in an effort to help streamline workflow and alleviate unnecessary stress to surgeons and OR staff.  Callisto eye integrates the actual happenings within the OR to preoperative planning and even follow-ups.

The Callisto eye systems touch screen allows data to be easily inputted and accessed.  This may include scheduling information, patient medical history, an overview of the scheduled procedure, information gathered as the procedure is actually being performed, and through the use of a barcode scanner a record of all consumables and medications used.  With all of the information just a touch away, it will aid in preventing unnecessary and costly mistakes.  In addition to all of the data applications, it also serves as a monitor and recording device that can be used in conjunction with the surgical microscope.  This allows for every step of the procedure to be traced and documented so that it can be reproduced for the future.

Ultimately, Callisto eye simplifies many cumbersome processes, increases efficiency and reduces workload, which reduces costs and increases the bottom-line.  More importantly, the comprehensive approach of this technology aids in assuring patient safety and quality results.

Clinical decision support preferable to subsidized EMRs

Many health policy experts believe that “if you subsidize it, they will come.” While that approach has worked in persuading people to take mass transit, it hasn’t lured many physicians into using EMRs.

Employers and hospitals will face financially more difficult times in 2009, and is time for managed healthcare executives to take a new look at diagnosis decision support (DDS), which will align physicians and hospitals in the shared goals of improving patient outcomes and reducing clinical risk This technology also comes at a much lower cost and can be rolled out much more quickly than EMRs.

DDS technology is not new. It has been available in various forms since 1986, but as computer hardware has become vastly more powerful, the newer versions of the systems have become faster and more practical for physicians to use. Many hospitals have adopted DDS in the past two years, as medical executives realize the importance of getting to the right diagnosis as fast as possible because of its effect on length of stay, appropriateness of testing and subsequent treatment and clinical risk.

DDS systems, as defined by a leading medical textbook, “link health observations with health knowledge to influence health choices by clinicians for improved health care.” They include two key components: a dynamic medical knowledge data base and an inference or logic engine to sort and select decision options for clinicians.

Early versions of DDS technology were frustratingly slow. At the heart of these early systems was a crude form of artificial intelligence (AI). The software required the input of multiple experts to provide semi-probabilistic relationships between thousands of clinical features and hundreds of diseases.

Physicians also spent a considerable amount of time interacting with them, answering a hierarchy of questions. Published trials reported that it took physicians 20 or 30 minutes to enter the data and arrive at a final set of decision options.

Dr. Robert Wachter is Associate Chairman of the Department of Medicine at the University of California, San Francisco and author of two books and a blog on hospital medicine. He has written of the frustrations and “overhyping” of the early diagnosis decision support programs.

According to Dr. Wachter, “the disappointment over the ineffectiveness of the early programs led to widespread skepticism that any DDS could help physicians be better diagnosticians.”

Today’s computer systems are thousands of times more powerful than those of the 1980s. This vastly improved performance has enabled a variety of different clinical decision support systems to be adopted in hospitals, large and small, across the country. DDS systems today provide clinicians with prescribing decision support, image recognition and interpretation, therapy planning and patient alerts.

One of the key reasons physicians have been reluctant to adopt EMRs in their practices is the hassle factor. Many medical groups have found that installation of an EMR shifts the burden of inputting patient medical information from nurses and clerical personnel to the physicians themselves and may reduce their patient flow (and potential income).

The new DDS systems largely avoid this problem. The physician might enter a few patient demographics (e.g. age, gender) and a few key words about the symptoms, and a list of likely diagnoses is often generated in seconds.

In addition, DDS systems have another key advantage, they reduce the rate of diagnostic error. Although rarely discussed, diagnostic error is a serious problem. A report in the May 2008 American Journal of Medicine found that diagnostic errors occur in 15% of all clinical medicine cases.

Dr. Wachter notes that until we resolve the issue of diagnostic errors, we face a fundamental problem in patient safety: A hospital can be seen as a high quality organization because for example, all of its pneumonia patients receive the correct antibiotics-even if every one of the diagnoses was wrong.

Joseph Britto, M.D., is chief executive officer of Isabel Healthcare in Falls Church, VA.

Physician Professional Development Requires Lifelong Learning

Lifelong learning is a concept that is being embraced by many industries, including healthcare, to emphasize ongoing personal and professional development that fosters knowledge growth and facilitates mastery in one’s field.

Known for decades as continuing medical education (CME), there is movement toward using the new term of continuing professional development (CPD) for physicians and surgeons. CPD is the structured vehicle by which professionals maintain, improve and broaden their knowledge, skill sets and core competencies, and develop the characteristics required by their profession. The Chartered Institute of Professional Development defines CPD as “the conscious updating of professional knowledge and the improvement of professional competence throughout a person’s working life. It is a commitment to being professional, keeping up to date and continuously seeking to improve. It is the key to optimizing a person’s career opportunities, both today and for the future.”

As medicine and healthcare undergo constant evolution and transformation, CME programs must keep pace with these changes to ensure that physicians have the best professional development resources available throughout their careers to translate new research into better patient care.

To that end, the Mayo Clinic convened a consensus conference in September that assembled more than 50 CME experts from the United States and Canada and also paved the way for a new CME enterprise. At the conference they established a blueprint for change designed to make CME a bridge to cost-effective, excellent healthcare and to ensure that CME serves as a lifelong centerpiece of physicians’ professional development.

A new CME enterprise will serve as a cohesive educational enterprise that links together the many disparate providers who now offer CME courses. Leaders say CME is currently too often an episodic, peripheral educational activity.

The conference was convened in response to a 2007 government report that concluded CME must become more rigorously scientific; more evidence-based and theory-driven; and more accountable to the public who entrust their health to physicians. Terrence Cascino, MD, executive dean of the College of Medicine at Mayo Clinic notes, “Our goal is to make CME focused and responsive to what is best for the patient.”

Over the next three years, conferees will collaborate to change CME using the following strategic imperatives to guide them. CME and its providers must:

• Function as a bridge to quality healthcare. CME’s mission is to help physicians and teams learn and improve, so the quality of healthcare services provided to patients also improves.
• Focus on collaborative best practices and patient-centered outcomes.
• Consider new instructional modes, such as issuing annual reviews of the best scientific literature in a field written both in a simplified style, as well as in the traditional scholarly scientific article format.
• Apply more widely and rigorously the science of quality improvement and its evidence to healthcare and physician practices.
• Ensure the highest ethics and integrity of healthcare information by eliminating conflicts of interest in CME offerings.

Richard Berger, MD, PhD, dean of the Mayo School of Continuing Medical Education and a professor of orthopedic surgery and anatomy, says the challenges to CME are urgent. “Doctors today must keep up with mountains of rapidly changing medical information needed to maintain a safe and up-to-date practice. Our task is to propose solutions based on sound learning theory, evidence and outcomes so we can integrate professional development through CME into physicians’ lifelong learning activities. With this conference the transformation of CME is underway.” The Mayo School of Continuing Education, formally organized in 1996, instructs more than 23,000 medical professionals annually through 200 courses.

Berger adds that transforming continuing professional development from episodic learning to more of a lifelong learning modality is a significant part of the purpose of the consensus conference. “We have established a mechanism for a coordinated national research agenda to formulate these strategies. What we do know is that several key elements must go into the lifelong learning process for healthcare workers to optimize their competence. This includes aligning the relevance of the education activity with scope of practice, transparent assessment of practice outcomes, and self assessment of knowledge and skills to detect gaps in competence, and then individualize learning processes to fill those gaps, strive toward point-of-care learning, recognize the effectiveness of team training, enhancing our awareness of and concurrence with validated practice guidelines founded upon evidence-based outcomes studies, with all of this embedded in a process of learning about quality and employing those lessons into everyday practice.”

Continuing medical educational leaders agreed to frame the CME improvement initiative as a “value proposition” that can motivate all stakeholders to seek it out and support it, from CME faculty members, to physician-students, to third-party payors, to hospital administrators, to members of the government. These leaders agreed that when CME is regarded as the first-line tool for improving healthcare and controlling medical costs through reduction of error and inefficiencies, everybody wins.

Murray Kopelow, MD, chief executive officer of the Accreditation Council for Continuing Medical Education (ACCME), comments, “We need CME that matters to patients and makes a direct, positive impact on patients by functioning as a reliable bridge to quality health care. We need this to be true everywhere CME is offered. And we need physicians to internalize lifelong learning as part of their professional identities. When this happens, patients can all be confident that his or her physician has the resources needed to keep up with evolving medical knowledge.”

As an increasing number of physicians explore new opportunities in health management organizations, integrated health systems, urgent care centers, physician group practices, ambulatory surgery centers and other healthcare facilities, they must possess the abilities that are critical in executive roles.2 Lois Lister, senior vice president and managing principal of the executive search division of Cejka Search, describes the aptitudes common among physicians: critical thinking skills, thoroughness, the ability to solve complex problems, strong motivation to be successful, and in many cases, the ability to work well with other physicians. Lister notes, however, “Medical training and clinical practice do not encourage development of all characteristics and habits that executives must have to succeed and advance into top-level positions.”

Berger says that it is imperative to define how CPD can support today’s physician’s practice skill sets. “We will be striving to learn more about how physicians and associated healthcare workers learn most effectively through a nationally coordinated research effort,” Berger explains. “Today’s physician has less time than ever to learn about more things than ever. The learning process needs to be as efficient and relevant as possible. We need to incorporate the core competencies, including communication and professionalism into as many learning opportunities as possible to strive toward the highest degree of integrity in practice as possible. There will need to be nimbleness to educational activities to keep them up to date, but at the same time recognizing the need for validation and evidence-based data.”

The challenge is that the vast majority of the more than 650,000 practicing physicians in the United States today have received little or no formal training in business administration. They have practiced medicine in a fee-for-service environment that has not required them to be aware of how the marketplace works and how a healthcare institution or practice must be run from a financial perspective. While they are clinical veterans, they are business novices in dire need of a new skill set that will help them navigate the choppy waters of post-managed care healthcare. Enter the physician MBA program. Although some physicians may have earned their master’s of business administration (MBA) degree through a traditional program, there are now MBA programs tailored specifically for physicians to prepare them for increasingly complex processes, systems and trends in the healthcare industry, including new reimbursement structures, increased public reporting, advanced quality improvement initiatives, and the nuts and bolts of day-to-day operations where clinical and business imperatives intersect in a healthcare facility. It’s a strategic mindset that isn’t part of the medical indoctrination but is essential to success in the fast-paced business world.

Francine R. Gaillour, MD, a business, career and executive coach for physicians and clinical leaders, and director of Creative Strategies in Physician Leadership, says that physicians should pursue an MBA in order to obtain a solid education in business, to learn the business world lingo, and to interact with other physicians who can help them broaden business knowledge, perspective and opportunities.4 There are dozens of established, accredited physician MBA programs around the country, according to the Association of American Medical Colleges, including offerings from the University of Tennessee, the University of California, Irvine has a Healthcare Executive MBA, and the University of Massachusetts, which offers an MBA through the American College of Physician Executives.

The focus of physician MBA programs should be on developing leadership skills and business acumen, according to Michael Stahl and Peter Dean, authors of The Physician’s Essential MBA, and members of the faculty of the University of Tennessee’s Physician Executive MBA program. Important subject matter that should be addressed in these kinds of programs, according to Stahl and Dean, include: strategic leadership principles, health policy and economics, skills for embracing change in a rapidly changing healthcare landscape, and more.

References:

1. http://www.cipd.co.uk/default.cipd
2. Pyrek KM. Making the Grade: Physician MBA Program Creates Medical Entrepreneurs and Physician Executives. Immediate Care Business. September 2007. Accessed at: http://www.immediatecarebusiness.com/articles/0791feat3.html
3. Lister L. 21st century physician executive: An in-depth look at healthcare recruitment in the 21st century. www.cejkasearch.com
4. Gaillour FR. Do You Need an MBA?  What do you learn in business school anyway? PhysicianLeadership.com. Accessed at: http://www.physicianleadership.com/articles/physician_MBA.htm
5. Association of American Medical Colleges. Group on Faculty Practice (GFP) MBA Programs for Executives and Physicians. Accessed at: http://www.aamc.org/members/gfp/mba.htm

Non-use of Patient Clinical Data a Greater Risk than Misuse

The recent launches of online health management tools Google Health and Microsoft HealthVault have re-ignited the mainstream debate about the privacy and security of personal health information. Despite its potential to dramatically improve the quality, safety and affordability of healthcare, many contend that the electronic sharing of clinical data among health care’s various stakeholders puts patient information at great risk of falling prey to cyber-criminals, illicit data mining operations or any number of other potentially dubious pursuits.

As examples of the type of privacy infringements we risk by automating health information, health information technology (IT) skeptics are quick to point to highly publicized incidents involving celebrities, such as those in which staff members at hospitals in New Jersey and California gained unauthorized access to the medical records of George Clooney and Britney Spears. Thankfully, neither celebrity was harmed as a result of the respective improprieties. Moreover, in each case, the people responsible for the infringements were appropriately reprimanded and, in the Clooney case, fired. Interestingly, neither incident was a matter of faulty security: the individuals involved actively chose to violate HIPAA and access the records.

In fairness, health IT isn’t 100% foolproof. Like any other record keeping methodology, there is a degree of security risk associated with it. However, these threats are no greater than those we assume when we shop or conduct our banking online. In fact, the most significant risk to the American healthcare system is not the misuse of information, it is the non-use of it.

As Dr. S. Robert Levine, chairman of the Health Priorities Project of the Progressive Policy Institute, said in his February 24, 2005, testimony before the National Commission on Vital Health Statistics: “…the greatest threat, the biggest risk to people with diabetes, or heart disease, or cancer, or HIV/AIDs or any other chronic disease or disability seems not to be from un-authorized sharing or use of their personal health information, rather it is from the failure to share or the inadequate use of that information, and sometimes even valuing protecting privacy over protecting an individual’s life, their health, and the health of their families, friends and neighbors.”

Not sharing existing clinical data is far more dangerous to us as individuals and as a society than any potential privacy risks associated with sharing it. Consider an unconscious accident victim presenting with severe injuries in an emergency department. With no knowledge of the individual’s medications, existing conditions, treatment history or other vital data, clinicians are forced to make fast, often life-altering decisions based solely on incomplete evidence gleaned from immediate observations.

The availability of more thorough clinical information — such as that found in an electronic health record — enables physicians to more accurately and efficiently diagnose and treat patients, and potentially save lives. On a larger scale, as Dr. Levine alludes, there are incalculable advantages to be gained from the use of clinical data in studying chronic diseases across communities and larger populations.

Health care IT offers far too many potential benefits to allow concerns over the misuse of information to paralyze its progress. Instead, we must begin focusing our collective energies on creating universally accepted definitions of exactly what the misuses of health information are. This will then enable us to thoughtfully formulate and expedite passage of legislation to help prevent such misuses and impose stringent penalties and punishments for those who do.

Efforts to ensure privacy while promoting the adoption of health IT must also incorporate two additional crucial components: critical mass and consumer choice. Any privacy solution we ultimately decide to pursue must be applicable to a majority of patients in order for physicians to more easily implement it, and to justify the expense, workflow adjustments and other infrastructural changes it will require. In this regard, the current opt-out model, which assumes that patients are willing to share their health information unless they specifically indicate otherwise, is favorable.

It allows the information for a vast majority of individuals to flow unimpeded. Additionally, it places little burden on providers and offers the greatest potential benefit to the largest amount of people, while preserving the rights of those who choose not to participate.

And patient rights are paramount. It is essential that health IT privacy regulations incorporate measures through which individuals who wish to exclusively control their medical information are enabled to do so. However, these individuals must be willing to accept this right knowing that, at least initially, their control choices will usually be limited to an encompassing “yes or no.”

Eventually, technology will enable more granular selectivity wherein patients can pick and choose the data they want to be made available and the respective physicians and other entities to whom they wish to grant access. Additionally, consumers will have to agree to assume responsibility for their opt-in/opt-out decisions. For example, if an individual chooses not to disclose certain information to a physician and then suffers an unfavorable outcome that that information would have helped avoid, the physician cannot be held liable. Patients — not the members of their care team — are solely responsible for the consequences of that decision.

The health information privacy debate is as complex as it is necessary. As the benefits of health IT continue to render themselves more apparent, it is essential that we develop technology that can improve healthcare — and save lives — that also simultaneously safeguards the confidentiality of very private information. In effect, we need to identify and maintain the balance of medical benefit and personal privacy. And as we work toward that goal, we must always be mindful that the greatest risk is not the remote possibility of data being misused, it’s not using data at all.

David St.Clair is the Founder and CEO of MEDecision, Inc.

Swindlers Still Swindling

In the past we had short change artist.  The smooth individual would be brazen enough to approach an unsuspecting (usually young) cashier and ask forchange for his/her large bill, usually $100 bill.  The artist would then change their mind on the size of bills to be given back to break the $100 bill.  The process by the short change artist was to get the $100 bill back in hand and also get change from the cashier also in hand.  The goal was to walk away with an additional $100 dollars in pocket by deception.

Today the short change artist has graduated to more sophisticated arts but is still trying deception.  In California the Department of Insurance announced the unsealing of criminal grand jury indictments in the largest medical fraud prosecution in the nation. Two defendants were charged for their role in the Unity Outpatient Surgery Center (Unity) scheme, in which $154 million was fraudulently billed to medical insurance companies.  Unity’s attorney, was indicted on 106 felony charges including two counts of conspiracy, eight counts of capping or paying for referrals, 30 counts of grand theft, 30 counts of insurance fraud, 30 counts of making false and fraudulent claims, one count of money laundering, one count of perjury, three counts of filing a false tax return, one count of failing to file tax returns, and white collar sentencing enhancements for taking over $2.5 million and $500,000.

Unity’s accountant, was indicted on 118 felony charges including two counts of conspiracy, eight counts of capping or paying for referrals, 30 counts of grand theft, 30 counts of insurance fraud, 30 counts of making false and fraudulent claims, one count of money laundering, nine counts of filing a false tax return, nine counts of failing to file tax returns, and white collar sentencing enhancements for taking over $2.5 million.

This indictment alleges a medical fraud factory operating an assembly line of unnecessary surgeries.  In addition to the attorney and accountant, we need to remember that it took surgeons to perform this masked artistry of medical fraud. The three doctors charged in this case are accused of participating in medical insurance fraud for performing medical procedures on healthy people with the knowledge that the patients were being recruited. Doctors The surgeons are accused of performing 1,037 procedures, resulting in insurance billings exceeding $30 million for the facilities fees alone. Unity received over $5.1 million in payment as a result of the surgeries performed by the doctors. 

 Many of the surgeries were performed on Saturdays and Sundays by the doctors. They often performed the same procedures on co-workers or members of the same household on the same day.  The doctors are accused of ignoring basic medical protocols such as: 1) Patients receiving surgeries on consecutive days instead of while under one anesthesia; 2) Doctors not meeting the patients prior to operating; 3) Doctors not following up with patients after the procedure was completed; and 4) Doctors not obtaining necessary medical information. 

 Our crazy world in which we live pulls me back to my mother’s quotations in regards to this sad escapade;

Thomas Jefferson

He, who permits himself to tell a lie once, finds it much easier to do it a second and third time, till at length it becomes habitual.

Sir Walter Scott

Oh what a tangled web we weave,
when first we practice to deceive!

Electronic Health Care Records Are Slowly Being Adopted

In Last Months Technology Section of The New York Times, columnist Steve Lohr wrote an article entitled “Most Doctors Aren’t Using Electronic Health Records.”  The article explored the disconnect between large health care providers, like Kaiser Permanente, the Mayo Clinic, the Cleveland Clinic, who have fully integrated the use of electronic health care records into their infrastructure, and smaller private medical practices/clinics who have yet to embrace the technology due to high cost concerns.  A government-sponsored study was published in The New England Journal of Medicine which reported that this problem has seemingly placed the health care industry at odds with itself.

Most doctors, who responded to the survey, support the movement towards a paperless health care record industry, but the costs associated with moving away from paper records do not provide enough economic incentive in many circumstances, especially with small private practices and clinics.  The article quotes Dr. Blackford Middleton, a health technology expert at Partners Healthcare, as saying that the market for electronic health care records is broken because “the people who gain financially are not the people who pay.”  That is to say that private and government insurers and hospitals can save money as a result of less paper handling, lower administration expenses and fewer unnecessary lab tests when connected to an electronic health care system, but the burden on many doctors still remains the initial investment of implementing such a program.

The government took steps in that direction when it announced a $150 million Medicare project that will offer doctors more incentives to move towards a paperless health care record environment.  Thus, one of the major issues, in regards to electronic health care records management, has more to do with cost prohibitions than industry acceptance of the technology.  From a privacy perspective, as the medical profession moves more and more towards a paperless system, the need for discernable metrics of retention policy and procedures will need to be addressed.  Doctors overwhelmingly are in favor of this technology because it will provide, among other things, a better quality of clinical decisions, avoidance of medication errors, and improve the delivery of preventative care.

The balancing of taking technology that is looked upon positively in an industry versus managing initial investment expenses, are factors which need to be treated with intelligible concern, otherwise, private patient medical information could wind up in the wrong hands.

To read more about the article, click here:  Most Doctors Aren’t Using Electronic Health Records

Google Health off and running

Google’s attempt to build a home for personal health records online could potentially make the ads more lucrative than Web search, a top equity analyst says.

After months of talk, Google on Thursday showed its Health program at a conference in Orlando. Google said it wouldn’t start out selling ads but wouldn’t rule it out. Google Health is expected to launch this year.

Gene Munster, an analyst at Piper Jaffray, firmly believes ads will happen. “Advertisers would pay absurd amounts of money to be seen when someone wants to, say, refill a subscription online,” he says. “This is more lucrative than commerce-related search.”

David Kessler, a former head of the Food and Drug Administration, calls the ability to access health histories a “major undertaking. I’ve run a hospital and am a physician, and I can’t even keep track of my family’s medical information.” He is one of more than 20 experts advising Google on its Health program.

Google and Microsoft, whose HealthVault started in October, among others, are trying to get medical records digitized is “The beginning of a new chapter in health care,” Kessler says.

Last week, Google announced a pilot program with The Cleveland Clinic.

“Many people have never even seen their health records, let alone their prescription history and lab results,” says Google Vice President Marissa Mayer. “Now, they’ll be able to.”

Mayer says the information can only be shared between a health provider and patient, though future versions will let you share with friends and family via a password.

Since announcing the program last week, privacy issues have fueled a lot of debate. Among potential scenarios: Say an employer finds your health records online and fires you over something in your medical history. “But those are human actions,” says Dr. Molly Coye, CEO of non-profit HealthTech, and another Google adviser. “They have nothing to do with the technology.”

Andrew Rocklin, a principal at Diamond Management & Technology Consulting, says paper records are more likely to be tampered with. “There’s a concern about having this online because it’s new and not part of our everyday lives, but as people get more used to it, they’ll see the benefit,” he says.

Sean Nolan, head of Microsoft’s health solutions group, says he’s signed up 17 partners to work with HealthVault, and expects to add New York Hospital and Johns Hopkins Hospital in the coming months. “The idea that I can have a persistent data connection with my doctors is super-exciting,” he says.

Source: Gannett

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