Dan Keller's Nursing, Health Policy
and
Healthcare Technology Blog

"The United States alone [among wealthy countries] treats health care as a commodity to be distributed according to the ability to pay rather than a social service to be distributed according to medical need."

-- JAMA (2003), 290, 798.

Contents
Nurses, learn informatics!Aug. 2016
Balancing actAug. 2016
It's the workflow, stupidAug. 2016
RN + Rx?July 2016
More war storiesJune 2016
Nurses are underservedJune 2016
War storyJune 2016
Bundling and engagementApr. 2016
PHC 62Mar. 2016
Little guysMar. 2016
Financial incentivesMar. 2016
Big dataMar. 2016
Vaccinations, revisitedMar. 2016
Healthcare Econ 101Feb. 2016
Obstacle? Opportunity!Feb. 2016
Get realFeb. 2016
Cool gigJan. 2016
Work to doNov. 2015
General ZuckerbergNov. 2015
Coding NursingNov. 2015
AMIA 2015Nov. 2015
Innovate!Nov. 2015
Boot campSep. 2015
Yes vaultSep. 2015
No vaultSep. 2015
Good vault?Aug. 2015
How sick?Aug. 2015
Nurses more than everAug. 2015
NumbersAug. 2015
Yes, patientsAug. 2015
Go Bernie! Go nurses!Aug. 2015
ACA for whom?Aug. 2015
Cool clear BrookeJuly 2015
Interopera-wha?June 2015
Defending their turfJune 2015
Dentist regentMay 2015
Woulda shouldaMay 2015
Nursing volunteerMay 2015
Military nursesMay 2015
OverkillMay 2015
BANIAApr. 2015
World dominationApr. 2015
HIMSS and HERSSApr. 2015
HIMSS15Apr. 2015
Patient-centric?Apr. 2015
We've come a long way...Apr. 2015
Pepsi applesApr. 2015
CountingJan. 2015
New GuyJan. 2015
PHC 57Dec. 2014
Supes vs sodaDec. 2014
23 and AnneDec. 2014
Pride and precisionDec. 2014
Playing with FHIRNov. 2014
AMIA!Nov. 2014
Et tu, RNs?Nov. 2014
Wise CuttingOct. 2014
Talking SenseOct. 2014
Lava MaeOct. 2014
Hey ObamaOct. 2014
SchmebolaOct. 2014
New VectorsSep. 2014
TeachersSep. 2014
Ebola GatesSep. 2014
Ebola deathSep. 2014
Corporate geneticsAug. 2014
A nurse heroAug. 2014
Talking soda taxAug. 2014
Ebola hysteria Aug. 2014
A garden to tend Aug. 2014
Medicare for all July 2014
Back in the saddle July 2014
Astro Truth July 2014
Health news July 2014
MU phase 2July 2014
Save VistAJuly 2014
Apple HealthJuly 2014
Vocabulary 101June 2014
End employer-providedMay 2014
ACA in real lifeApr. 2014
Go SFApr. 2014
New ModelMar. 2014
Too HIPAAMar. 2014
Big soda spendingMar. 2014
Who was first?Mar. 2014
How we dieMar. 2014
Big sodaFeb. 2014
Politics or health?Jan. 2014
Disaster notJan. 2014
Wing nutsDec. 2013
Heroic senatorDec. 2013
More homelessDec. 2013
Nurses nextDec. 2013
Empire emergingDec. 2013
Obamacare and meOct. 2013
Future now Sep. 2013
Get Social Sep. 2013
Bedside blogger Aug. 2013
Homeless connect Aug. 2013
Mere apps Aug. 2013
Roadmap to Single-Payer July 2013
Nursing Iceberg July 2013
Gimme Data June 2013
Simple Dollar May 2013
Data ownership, redux Apr. 2013
Doc-by-mail? Mar. 2013
Biggest carriers Jan. 2013
Not a moment too soon Dec. 2012
Partisans Dec. 2012
Against the tide Dec. 2012
Scan this! Dec. 2012
Being Present Sept. 2012
UCSF's APeX Go-Live June 2012
Silent organs Jan. 2012
Lateral violence Dec. 2011
Healthcare and advertising Nov. 2011
UC is in trouble Sep. 2011
Greedy nurses? Sep. 2011
Hear us roar!Sept. 2011
Strikes, yikes!Sept. 2011
Trimming the fatSept. 2011
New fraudSept. 2011
National Health IT WeekSept. 2011
Doctors and nurses are not enoughJuly 2011
A good guy at the topJuly 2011
You'll be safe hereJuly 2011
Google Health is deadJune 2011
Cancer cures?May 2011
Woo Hoo! We're Winning!May 2011
Record Profits for Health InsurersMay 2011
Foreshadowing things to come? May 2011
Non-Profit in Name OnlyMay 1, 2011
Calif. Universal Healthcare Act Apr. 2011
Beware the 3 Ds Apr. 2011
Quantity or Quality? Apr. 2011
Words! Mar. 2011
Start Something Feb. 2011
Government = Inefficient? Feb. 2011
Mind = Brain? Feb. 2011
Capped! Feb. 2011
Planning for prevention Feb. 2011
Penny-wise... Jan. 2011
Pinned! Dec. 2010
Men at work Dec. 2010
Dear diary Dec. 2010
Brainy nurses Dec. 2010
Emergency! Dec. 2010
Public option, public sector Nov. 2010
Change the world Oct. 2010
Want a hero? Or a checklist? Oct. 2010
Environursing Oct. 2010
Don't call it compliance Sep. 2010
Shoppin' spree? Aug. 2010
Double mandate? Make it triple! Aug. 2010
Control your own medical data? Try it! May 2010
Conformity and stethoscopes May 2010
Do nurses compute? Apr. 2010
Addiction phobia Apr. 2010
Krugman nails it again Mar. 2010
Recognizing diabetes Mar. 2010
A new stethoscope... and a sermon Mar. 2010
Blame the Lawyers Feb. 2010
Turkeys voting for Christmas Jan. 2010
The Incentive that Works Dec. 2009
Doctors? Businessmen? Or Both? Nov. 2009
Gullibles, Libertarians, Partisans, Shills Sep. 2009
Speier Gets It! Sep. 2009
Snowe Job June 2009
Chronic Disease Management Systems May 2009
Vaccinate! Jan. 2009
Health Sites Jan. 2009
Obama Gets It! Jan. 2009
Unfair Advantages? Now We're Getting Somewhere! Jan. 2009
USHealthCrisis.com: Another One for Francine Jan. 2009
Google Health knows when you're sick Nov. 2008
Heart Attack Grill Nov. 2008
How Do Italians Pay for It? Oct. 2008
Yes on California Senate Bill 840!Sep. 2008
Pat Rants Aug. 2008
The Medical-Industrial Complex July 2008
Nosocomial Infections June 2008
Gore Gets It! May 2008
Kucinich Gets It! Apr. 2008
Neurosurgery in Vietnam Mar. 2008
How Do Americans Pay for It? Mar. 2008
Google Gets It Mar. 2008
Surprised! ...Again Feb. 2008
The Electronic Medical Record (EMR): Still WaitingJan. 2008
A Medical System to be Ashamed Of!Dec. 2007
Gavin Gets It! Sep. 2007
Cato Schmato Sep. 2007
Do You Read Me? Aug. 2007
Getting Clear about Single Payer May 2007
Eliminating the middle man is not "socialized medicine"Feb. 2007
Medicine in the Post-Oil World Jan. 2007
Getting It Explained? July 2006
Pritikin's Still Got It! June 2006
No Butts May 2006
Help for Nurses On the Job? Apr. 2006
Beat It Mar. 2006
Homework-O-Matic Feb. 2006
That Is Sick! Jan. 2006
Go Aussies! Dec. 2005
Healthcare's shifting paradigms Nov. 2005
What Do You Mean I Don't Own My Own Medical Data?Oct. 2005
Higher Education: Revolution NeededSep. 2005
Doesn't Compute Aug. 2005
Providing Emotional Support July 2005
Don't Just Protect Me, Put Me in Charge!June 2005
The Art of Volunteering May 2005
About Dan

 
Nurses,
learn
informatics!

August, 2016 -- Why learn informatics? Effectiveness on the job (we all use computers every day). Advocate knowledgeably for nursing in technology decision-making. And more... These things are important! Our ineffectiveness with technology holds us back as professionals and as industry strategists.

How should we learn informatics? Read my brief article, Nurses, Learn Informatics!

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Balancing
act

August, 2016 -- You’d think that everybody in health care would want the same thing: health. More formally, we call that outcomes; the goal of doctors, nurses, and of course, patients should be the achievement of the best possible outcome in the situation, even if that is, say, a death with pain minimized, or a chronic disease managed. But it’s not so.

However, the wants of each player are surprisingly different. Here I’ll discuss the situation that is most familiar to me, the acute care hospital. When he is there, the patient wants meals, to be warm, to receive timely responses to his call bell, and to be helped to the bathroom ASAP.

The nurse, on the other hand, has quite a different list of wants. She wants to know clinical data such as WBC (white blood cell count, a measure of response to infection) as part of her mental model of her patient’s health status, to be able to deliver meds on time because that is an important measure of her performance, to prevent falls and bedsores because these are indicators of quality of nursing care, to be confident of the appropriateness of meds orders since she, ultimately, is the one administering them, and that pain meds are adequate because she is the one witnessing suffering and managing it within parameters determined by others.

Sometimes these differing goals are in conflict. For example, going to the bathroom might risk a fall. Letting a patient sleep undisturbed might risk a pressure ulcer (bedsore). In summary, health care processes are complex and the motivations of its participants are surprisingly divergent. Managing all this so that all needs are met is a remarkable balancing act that nurses do every day.

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It's
the
workflow,
stupid

August, 2016 -- When nurses complain that the technology-based tools (especially EHRs) that they are tasked to use slow them down, usually what they mean is that these tools don’t model their workflow. We talk about workflow a lot! But what is it? Why is it so important? And why is it so hard to model with computerized/electronic/mobile tools?

Please see my August 2016 NurseMind blog entry for the full story.

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RN
+
Rx?

July, 2016 -- Should RNs prescribe pain meds? Our scope of practice denies us this important function, perhaps appropriately so. We don’t want this responsibility but we often want more participation in the decision. Often, the order is insufficient and the patient is suffering (perhaps due to the prescriber's addiction phobia), or it is excessive and the patient is being snowed.

The RN is more in touch with the patient from moment to moment and, at least in terms of pain, often has a better sense than the MD of what’s really going on.

We do have a professional certification for pain management and even the American Society for Pain Management Nursing but even the best-equipped nurse can be no more than a "caring advocate" and an advisory (not decision-making) member of the professional team.

Is it time to enlarge our scope of practice?

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More
war
stories

June, 2016 -- Here are some more war stories, focused on issues with the EMR. My friend Pat works in a peri-op unit, so her stories relate to that workflow. Here are four.

The patient's chart says NKA (no known allergies), and that it's been reviewed by another RN. However, at admission, the patient says yes, they do have allergies to several meds. So she asked the RN who was recorded as having reviewed the allergies field in the chart why they weren't there. That RN said, allergies weren't relevant at the time; I was working on something else and had to click through that screen to get to the part where I could do what I needed to do. In other words, the EMR did not model that nurse's workflow. A potentially serious medical error was narrowly averted.

When you scan a document, a stripchart, or an image into the EMR, you must name it. What name should you use? Into which folder should you store it? There is no standard. Different departments use different conventions. Thus, it is often difficult to find a document or image scanned by someone in another department. You must call and ask them what it is called and where to find it in the EMR.

HIPAA rules create obstacles. For example, a patient recently had an EKG at another site and didn't sign a release. The RN at our site needs to see the EKG in preparing the patient for the OR. So she gets another (redundant, expensive) EKG. This is quicker than attempting to obtain access to the existing one and enables Pat to get the patient to the OR on time.

Reconciling a patient's meds must be done in preparation for an OR procedure. It takes an hour to do. Shortly thereafter, the doctor or the patient decides to delay the procedure by a week. A week later, when the RN re-does the admission process, she cannot find the existing medication list and must repeat the one-hour reconciliation process though nothing has changed. The information is in the system somewhere but the RN can't find it.

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Nurses
are
underserved

June, 2016 -- Nurses are surprisingly underserved by technology. Paradoxically, much of what they do involves computers and complex electronics such as pumps and monitors. In particular, nurses spend a lot of time working with electronic medical records. However, these tools are patient-centric, not nurse-centric. In other words, using these tools, nurses contribute substantially to the quality of patient record-keeping, care delivery, and billing, but the tools do little to support the work of nurses themselves. Thus, we observe that there is a large gap in the spectrum of nursing knowledge- and process-based tools.

The reasons are twofold. First is economics: nursing is a cost center rather than a revenue center. Unlike medical procedures and supplies, most of what nurses do is not directly billable. For example, an appendectomy or a pill generates a charge on a bill for which a medical institution is paid, whereas most of the expense of nursing is, from the financial standpoint of the institution, overhead. The cost of most nursing care does not appear as line items on medical bills; it is bundled into hospital room rates and into the charges for procedures. As with all bundled expenses, the incentive is to reduce them. Whenever possible, spend less on nursing. This makes tools for nurses hard to sell and thus industry rarely develops them.

The second reason is the complexity of nursing work and its workflow. At Nurse Tech, Inc., we have given this much thought and propose that a good starting place is, as Drs. Gawande and Pronovost have done for surgeons, the creation of checklists for nurses (NurseMind). Since nursing work -- unlike surgeries that are discrete units of work, usually comprising a clearly-defined set of goals and predictable sequences of branching paths through the course of procedures -- encompasses entire work shifts and are more varied and fluid in how their content evolves as the work proceeds, they would be more difficult to capture in static printed checklists. Rather, they require the more complex support that can be provided by sophisticated algorithms (such as the one we have patented) on mobile devices such as smartphones.

In this environment, an app can build nursing task lists by drawing on a variety of sources: nursing units' descriptions of how they provide care (e.g. who takes vital signs? who manages physical resources such as carts and trays?), what diagnoses patients have that demand additional nursing tasks (e.g. diabetes care, central and intravenous lines, catheters), new orders that are received during the course of the shift, changes in patient status, and follow-ups (e.g. lab results, communications with colleagues, requests from families) that must be remembered. The context and its demands are fluid and rapidly changing, and the checklist tool must reflect that without slowing the nurse down. We believe that in the app we have built we have largely satisfied these demanding and complex goals.

No app can substitute for the nurses' clinical judgment and critical thinking. In early versions we attempted to build algorithms for assigning priorities to tasks but soon concluded that there is no way to automate this. However, it is appropriate for nurses to have tools that support them in the routine parts of their work. This enables them to make fewer omissions and consistently deliver top-quality care. Most importantly, by relieving he cognitive burdens of the routine work, mental space is freed for the higher level thought processes.

It is time for nursing to receive the technology support that it needs and deserves.

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War
story

June, 2016 -- I love the war stories recounted by nurse heroes. Here is one by my friend Terri Olson. She recounts:

In 1984, I went to Eagle Pass, Texas for a travel nurse assignment. There I saw some things I will never forget.

The hospital had a splendid view of the Rio Grande. From the windows, we could see people wading over from Mexico to deliver their babies. Thankfully, in recent years the quality of care in Mexico has mostly caught up with ours.

I was assigned to a med/surg unit, which was where they put patients of every description. Med/surg served as the catch-all unit, providing services that should have had specialized units such as peri-op. We received patients directly from the OR on monitors and requiring constant surveillance. However, the monitors were in the patient rooms not at the nursing station, so we were unable to watch them. So I literally ran from room to room in constant panic hoping I wouldn't walk in and find a dead patient. None of the other hospital staff thought that was a big deal. I had a hissy fit and quit after six weeks. Thankfully, the design of hospital nursing units has gotten a lot better since then.

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Bundling
and
engagement

April 5, 2016 -- Today I attended Northern California HIMSS's 4th Annual Patient Engagement Summit at Stanford University. A majority of the attendees were, like me, vendors of healthcare technology. The experience was most worthwhile. We all learned a lot.

Perhaps the most interesting session was entitled Payer Challenges. Payers include insurance companies, health plans, and the data analysts who work for them. It was eye-opening to hear their side of the healthcare story.

We learned that this month, under a provision of the ACA, bundled payments have gone into effect. This replaces -- on a voluntary basis -- the more traditional and likely less effective (from a cost-savings and quality-of-outcomes viewpoint) fee-for-service payments.

At the CMS web site, the concept of bundled payments is described:

Traditionally, Medicare makes separate payments to providers for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings. Payment rewards the quantity of services offered by providers rather than the quality of care furnished. Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners – allowing them to work closely together across all specialties and settings.
A bundled payment is for a single episode of care (e.g. a hip replacement) and is made to a hospital that then pays the various caregivers such as the surgeon, the physical therapist, the pharmacist, etc.

The amount of the payment remains fixed even when the patient must be readmitted to the hospital within 90 days. If that happens, the hospital will likely lose money.

Thus, the incentive is strong to coordinate caregivers to work as a team, focusing above all on outcomes thus avoiding that readmission. Indeed, research has shown that the incentive works -- costs go down and quality of care goes up. Here is a brief tutorial and video about bundled payments.

Not by accident, an effect of bundling payments is the incentive for patient engagement, the topic of today's conference. Involving the patient in their own care is essential for good outcomes. Also, the provider becomes motivated to pay attention to patient-reported outcomes. Now the financial rewards are aligned with these care-improving behaviors.

I have written about this concept of patient engagement in a different context, that of healthcare's shifting paradigms. The old paradigm was discharge planning. Now we strive for lifestyle change.

Today's conference was timely indeed.

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PHC
62

March 23, 2016 -- Another amazing day (#62) with Project Homeless Connect.

I saw sixteen patients. Yes, we're supposed to call them clients, but their medical needs were so great. I saw meth users, a MRSA victim with an active infection, lots of lice, a paranoid/schizophrenic, and a guy who had been awake two days straight, walking around the city, because he has no place to lie down.

PHC provides an amazing array of services, everything from assistance with banking to foot washing, truly a valuable contribution. It's tragic, though, that society at large does little for these folks; it falls to volunteers like me and the heroes who run PHC. Is that any way to run a country?

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Little
guys

March 18, 2016 -- Sometimes it's not the big guys who are at the top of the nursing education game.

Unlike the major nursing schools of the Bay Area, little Holy Name U. has Nursing Informatics course offerings in its curriculum. Not only do the bigger players (I won't name names, but you know them!) have no such courses, they are not interested. Given that today's nurses spend more time in front of the computer than in front of the patient, why don't all the schools do what HNU is doing?

Today I attended HNU's annual nursing symposium. Though the essential purpose of events such as this one is recruitment, I did learn a lot and found the majority of the presentations valuable and even eye-opening. Go little guys!

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Financial
incentives

March, 2016 -- I believe that people who call for abolition of the ACA would not do so if they knew what's in it. So here's another little bit of ACA 101.

We all want better, cheaper healthcare. The ACA drives improvements in quality and decreases in the cost of healthcare. One of the mechanisms for accomplishing this is financial incentive. The ACA has three specific financial incentive programs:

  • Value based purchasing (VBP) — outcomes, satisfaction, quality, safety — metrics that drive "booster" payments.
  • Readmission reduction program (RRP) — reduce 30-day all-cause readmissions for patients with CHF, pneumonia, and other conditions that can best be treated at home. This can be accomplished through coordination of care providers, patient education, and more.
  • Hospital-acquired conditions (HAC) — Medicare and various ACA programs no longer reimburse for the curing of falls, air embolisms, urinary tract infections, central line-associated blood stream infections, surgical site infections, and various others including MRSA, CDI (Clostridium Difficile infxn).

These are all common sense, evidence-based measures to help change healthcare in directions we all support.

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Big
Data

March, 2016 -- Can machines discover medical knowledge? In a frank interview with Dana Ludwig, MD, this notion and many more are discussed.

Medical data is huge and complex. The Epic electronic health record alone has 13,000 tables, and there are many more databases to mine. Ludwig says,

Machine learning algorithms might find associations that I don't know about by crawling through the massive tables. Given the 100,000 variables that we have on line, have the machines crawl through and see which ones are predictive of [some] diagnosis code. I don't know whether the algorithms can do a better job than the experts can do, but I'd like to find out. The goal of the neural networks is to let the algorithm discover the attributes that are predictive rather than presupposing that the experts can name them.

Can machines make discoveries that human experts cannot? Read the interview here.

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Vaccinations
Revisited

March, 2016 -- Remember back in 2009 when I listed all the vaccinations?

Here's the real list, the CDC's Code Set CVX -- Vaccines Administered.

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Healthcare
Econ 101

February, 2016 -- With ours being the most expensive healthcare system ever, its economics are increasingly topics of debate. Here are a few basic principles that drive our dysfunctional system.

Financial reward motivates every business, healthcare among them. What is rewarded increases. In an ideal system, providers are rewarded for good outcomes. There are some incentives for this in the ACA and in Medicare including patient satisfaction surveys that have been made a factor in hospital reimbursement by government. However, in healthcare's predominant economic models, the rewards are neither for outcomes nor for quality.

One such traditional model is fee-for-service. The result is, of course, more service. (This was discussed in my blog post Doctors as Businessmen.)

Another common model is capitation. A provider network is reimbursed a fixed amount for each patient. So the result is more patients. In capitation models, the scramble is for market share.

In any model, the physician says, when the patient is in front of me, he is the most important person. After he leaves, the most important person is the payer.

The conclusion: healthcare and economics will always be an uneasy mix.

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Obstacle?
Opportunity!

February, 2016 -- The first obstacle a new grad nurse encounters is the dearth of jobs for new grads. It's easy to get into nursing school. Afterward, it's hard to get that first job. The schools don't tell us this.

Reluctance to hire new grads is understandable from the hospitals' point of view; a new nurse is a big investment. It can be months before she (almost always a she; my graduating class was 85% female) reaches full productivity.

Something that is also not discussed is the content of nursing education. The schools are obsolete!

What I saw in nursing school: a bunch of grizzled old farts who couldn't cut it as actual nurses ("those who can't, teach") and who haven't kept up with the rapidly-changing world of healthcare.

Case in point: today's nurse spends quite literally more time in front of computers than in front of patients (proven by numerous studies). Yet informatics courses in nursing school curricula are rare.

Even at national leader UCSF, my alma mater, Dean Vlahov declined my request to meet to talk about this.

The result? Nurses helpless and frustrated by technology, decreased productivity and reduced safety, defying nursing's #1 mandate.

The upside? This is an opportunity. My software projects will enable technology to be a help rather than an obstacle for nursing.

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Get
real

February, 2016 -- In today's climate of presidential campaigns, right-wingers are still calling for repeal of the ACA? Get real!

Deep down, those echo chambers know how badly that would backfire.

Insurance companies -- huge campaign donors -- would see a steep drop in profits. Lots of ordinary folk would suddenly lose healthcare coverage. People with "prior conditions" would be back out in the cold. Medical bankruptcies would resume. Hospital and provider revenue streams would be disrupted. A lot of people would be very angry.

I think what's happening is -- as they do with environmental and other regulation -- the right-wingers clamor in public but in private they count on cooler heads to keep them safe.

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Cool
gig

January, 2016 -- Here is Dr. Dan Weberg RN speaking at a medical technology conference.

He works for Kaiser. His title is Director of Nursing Innovation.

Doesn't that sound like the coolest gig in the world?

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Work
to
do

November 18, 2015 -- Today at the AMIA conference, Dr. Bob Wachter, faculty member of my alma mater UCSF and author of the thought-provoking The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age, gave a great talk on that theme.

As is unmistakeable in this wonderful image he showed -- "A 7-year old girl's depiction of her MD visit" -- in which the MD is completely focused on his computer not on the patient (click to see it full-size) we in medical technology have a lot of work to do.

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General
Zuckerberg

November 21, 2015 -- Today I attended the ribbon-cutting dedication of the new Priscilla and Mark Zuckerberg San Francisco General Hospital (SFGH) and Trauma Center building. Present at the occasion were Zuckerberg (in his trademark tee-shirt and jeans, chatting with California Lieutenant Governor Gavin Newsom in my photo), Congresswomen Nancy Pelosi and Jackie Speier, San Francisco Mayor Ed Lee (wielding the giant scissors), venerable news anchor Belva Davis, and many more.

The building itself ($880 million) was paid for by a City bond. Zuckerberg's gift of $75 million paid for the equipment and technology inside it.

We toured the new facility. It is the most efficient, high-tech and well-designed emergency department I've seen. Having volunteered in its predecessor (across the courtyard, still running) I have seen the superb medical care that is delivered here. When the new facility opens in March, 2016, it will be even better.

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Coding
Nursing

November 18, 2015 -- Here is another reflection following the American Medical Informatics Association's 2015 meeting (AMIA) that ended today. It regards data coding standards for nursing and is woefully neglected, even here at AMIA. The topic is important for nursing because without a good coding scheme, we cannot capture data about what we do. Without that data, we cannot make the important case for the value that we create for healthcare.

As I have discussed here, there are several encoding schemes for nursing data. The best one for the purposes of nursing and data processing is Virgina Saba's (about whom I blogged briefly here) Clinical Care Classification System but alas it hasn't received the wide uptake it deserves.

Dr. Saba herself attended the conference (we lunched) and -- as one of the grand dames of nursing informatics -- presented the Virginia K. Saba Informatics Award.

At AMIA, the only nursing coding scheme I saw discussed was International Classification for Nursing Practice (ICNP), an international standard and nursing-centered but not as well suited for computerization. Perhaps this is an area for discussion at a future AMIA.

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AMIA
2015

November 18, 2015 -- Today was the closing day of the American Medical Informatics Association's 2015 meeting (AMIA). As always, I learned a lot from the technical talks and came up to date on issues and trends in this busy, burgeoning industry.

The closing keynote speech was by Dr. Bob Wachter (here is his blog, Wachter's World) in which he gave us an impassioned exhortation to remedy the numerous ills of healthcare IT. The audience clapped frequently, sharing his enthusiasm for the as-yet-to-be-realized potential (and numerous humorously-described flaws) of the immature technology we're all working on. For example, he observed that it is not enough to write good software; we must also reimagine the work itself.

Wachter's talk largely paraphrased his recent book, The Digital Doctor that I have mentioned here and of which I promise a review soon. The book was a terrific read and the speech today was equally heartening.

Go Bob! Go AMIA!

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Innovate!

November 12, 2015 -- Today I toured Kaiser's Garfield Innovation Center where they simulate hospital and home environments for testing new technologies and refining caregiver workflows.

As with the military, Kaiser's processes for evaluating, selecting, testing and rolling out new tools and technologies are ponderous and lengthy. Often, by the time all the maintenance and support procedures are implemented, impacted work processes are updated, and staff are trained, the tool or tech is old news. But there are no short cuts. When you are steering a battleship, you must turn the wheel five miles before the ship responds.

One such innovative change touted at Garfield that is already old hat to us nurses is the don't-interrupt-me-while-I give-meds yellow sash. Simple as it is, it does work. Uninterrupted, the nurse is less likely to make a medication administration error. Yet it had to be tested in a safe environment, and the Garfield Center served this purpose well. Today, most nurses in hospitals use these sashes (or something similar) and error rates have gone down.

Another new technology -- this one dear to me as a proponent of mobile solutions for nurses (such as my NurseMind app) -- is smartphones. Kaiser is evaluating various ruggedized versions and deploying them for a variety of purposes such as secure messaging. I hope they will also consider checklists such as the nursing one I have built... And deploy it at the Garfield Center!

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Boot
camp

September, 2015 -- Nursing Informatics Boot Camp was this week. Organized by the Northern California chapter of HIMSS (thanks!)

The instructor was my friend Susan Newbold. She knows her stuff. Glad I went!

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Yes vault!

September, 2015 -- Success! Kaiser and Epic came through after all. And so did HealthVault.

If you're a Kaiser member, you can download the last five years or so of your electronic health record in CCR format. Here is how:

  1. Login to Kaiser's web site.
  2. Find the medical record page and click the download link. You'll get a zipfile.
  3. In the zipfile, find the file named DOC0001.XML
  4. Upload it to your HealthVault account. Bingo!

And thank Obamacare Meaningful Use Stage 2. We can all have our data in our PHRs now. Hurray!

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No vault

September, 2015 -- Here's the main part of the letter Microsoft HealthVault provided for me to send to my health care provider (Kaiser):

	Please send my medical information from your medical
	records system directly to my personal HealthVault
	record using my Direct address.

	I'm taking an active role in my health and wellness
	by keeping a personal health record in HealthVault.

	If you are using an electronic health record (EHR)
	system that is certified for Meaningful Use Stage 2,
	then your software may be able to generate a CCDA
	and send it to me using the Direct protocol.

	(As you may know, Direct is a security-enhanced
	health messaging protocol designed to help protect
	health information when it is sent from one
	computer system to another.) Your EHR software
	vendor should be able to provide instructions.

	    [Kaiser uses Epic...  Amazingly, it's not
	    retrofitted for MU2! See below.]

	Please read How healthcare providers
	can benefit from HealthVault (fascinating!)
	for more information about HealthVault and
	how it supports Meaningful Use Stage 2 (MU2).
	

I sent that letter to my Kaiser doctor.

Here's what my doctor wrote back:

	Daniel S Keller
	From: [Nameless MD]
	Received: 8/27/2015  4:26 PM PDT

	Hi Dan - Sorry I am unable to do that directly.
	All our Epic secure messages must go through our system.
	You will always need to log into KP.org to retrieve them,
	though you will get a notice to your regular email saying
	you have a message. I have nothing to do with the system
	or contacting the vendor. You can get your medical record
	on a thumb drive. You can go to member services for that.
	The phone number for Member Services is 1-800-464-4000.
	They may be able to help with your questions about
	HealthVault, too.

	Hope that helps.
	Best,
	[Nameless MD]
	

Turns out you can only get a CD, and it contains only PDFs of your medical record. In other words, Epic (with Kaiser's collusion?) is making sure you cannot do what HealthVault and I are trying to do.

Discussions with Kaiser's medical records department member support people were pointless. They had never heard of CCD nor even MU.

So Epic sucks again. I hope their customers (ahem, Kaiser?) find a vendor who actually delivers on MU2. Go HealthVault!

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Good vault?

August, 2015 -- Here are some things I like about a PHR (personal health record) such as Microsoft HealthVault:

  • It could free me from those sucky "patient portals" such as Kaiser's HealthConnect, one of Epic's "features" that primarily serves the institution and only secondarily the patient (as I've blogged here and here).
  • It gives me a little more access to my data, and a little more control over it. I can actually enter and update my medical data myself and, to a limited degree, grant access to it to others.
  • The Continuity of Care Document (CCD) protocol/format is a long-overdue advance from lame old HL7. It is a good thing and should be universal.
  • Another good thing in Obamacare is MU2's requirement that health care providers exchange data including patient demographics, problems, test results, immunizations, allergies, care plans, and more. Here are some of its objectives:
    • Use secure electronic messaging to communicate with patients on relevant health information.
    • Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (eMAR) (for hospitals).
    • Provide patients the ability to view online, download and transmit their health information within four business days of the information being available to the eligible provider (EP).
    • Provide patients the ability to view online, download and transmit their health information within 36 hours after discharge from the hospital (for hospitals).

Go HealthVault!

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How
sick?

August, 2015 -- An issue of perpetual contention in nursing is staffing. How many nurses do we need on staff right now, for the present patient load? Management wants fewer (to save money) and nurses want more (to get all the work done). Where's the science?

One way to make staffing decisions is based on acuity -- how sick are your patients? Today, staffing decisions are based on crude estimates drawn from patient diagnoses. If they're very sick, hire more nurses.

But there is a better way. Degree of sickness is not the best indicator of nursing workload. Instead, I propose a measure of acuity that is the number of minutes of nursing work remaining to be done for each patient. Nurse managers would, in real-time, use a tool that adds up all the durations of the outstanding tasks for each of the patients currently on the unit. A lot of minutes means you need more nurses. How many? Divide the minutes into the duration of a shift. Voila! Accurate nurse staffing!

This measure was developed working with seasoned veteran emergency/charge RN Mark Wandro. We propose a study to confirm that this new measurement of acuity (and the tools that support it) can improve nursing outcomes.

Is your hospital interested? Can you sponsor this study? Please get in touch! Let's make nursing better!

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Nurses
more
than
ever

August, 2015 -- In this videoed interview with Pam Cipriano entitled Why Nurses Matter More than Ever, Ms Cipriano -- an old guard union booster -- makes an important point. But it's based on nursing's traditional battle about staffing levels. This pits us directly against management that seeks to hold down costs. Recall, payroll is a hospital's single largest expense. Nurses are often its largest component.

Ms Cipriano is right but for reasons other than what she states. Now reimbursements -- thanks to the ACA -- are partly based on quality measures and, most importantly, on outcomes. In its central role, the quality of nursing care has risen to what is perhaps the most essential factor in determining outcomes.

Our union does an important job in enabling us to work well but we need to move beyond those tired formulae and focus on how we deliver the high quality health care that America demands. What we nurses need to enable us to deliver these ever-better results should be the goal for which our union contends. Ms Cipriano fights a good fight but could do better by enlarging her goals. Adequate staffing is necessary but not sufficient. We also need tools (especially mobile ones such as NurseMind), participation in decision-making, representation in the C-suite (every substantial health care organization should have a CNIO), evidence-based protocols, and much more.

In Nursing: Essential to Healthcare Value in Nurse Leader, a model begins to emerge. Authors Pappas and Welton propose to "...define nursing value as the function of outcomes divided by costs." The model is rudimentary but it's a good start. What you can't measure you can't manage. The model begins to tell us what to measure.

The point is that, with reimbursements tied more than ever to outcomes and perceptions of quality, nurses are essential to health care revenue. Hospitals, make sure your nurses have what they need to deliver the results you need. When we do our work well, you are reimbursed well and -- most importantly -- patients get good care.

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Numbers

August, 2015 -- The numbers are in. The homeless have been counted. I was one of 400 volunteer counters on Jan. 30th as I recounted then.

But first, how exactly is homelessness defined? The federal government's definition excludes many whom we in SF consider homeless. They exclude:

...individuals who are "doubled-up" in the homes of family or friends, staying in jails, hospitals, and rehabilitation facilities, families living in Single Room Occupancy (SRO) units, and in substandard or inadequate living conditions including overcrowded spaces.
In accordance with the federal rules, we did not report the numbers of these people, but we hope that eventually they, too, will be included and eligible to receive the services they, too, need.

Here is a summary of what we found in the 49 square miles that comprise San Francisco:

  • 6686 homeless adults, 250 more than were counted in 2013
  • 853 homeless youth, 61 fewer than in 2013.
For the details, please see the full report.

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Yes, patients

August 12, 2015 -- Fascinating meeting today with Dr. Howard Landa, CMIO of Alameda Health System. He is implementing EHRs in their five-hospital system. Though his job is technology, his thinking is all about the patient.

In describing the systems his team builds, he regularly refers back to what patients need, what they experience, and the quality of what's delivered to them.

When we do our jobs right, this is how we do them. Thank you, Howard. You are a great role model!

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Go Bernie!
Go nurses!

August 10, 2015 -- National Nurses United (NNU), our Washington advocacy group, has officially announced our endorsement of the candidacy of Bernie Sanders for President. Here in Oakland, no less. (I have extolled his principled positions on prior occasions.) In this picture he is with Executive Director RoseAnn DeMoro who says, "His issues align with nurses from top to bottom." Please read the press release for details.

Once again, we nurses are on the right side of history!

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ACA
for
whom?

August, 2015 -- The ACA has delivered substantial benefits for many Americans but the citizenry is not its primary beneficiary. In an excellent July, 2015 article entitled "Wrong Prescription? The failed promise of the Affordable Care Act", Trudy Lieberman in Harpers Magazine reviews what we've learned in the five years since its passage.

"[It] was a canny restructuring of the American health-care marketplace, one that delivered millions of new customers to insurance companies, created new payment mechanisms for hospitals, steered more business to pharmaceutical companies, and dictated expensive, high-tech solutions for a wide range of problems."

Though medical bankruptcies seem likely to diminish, 17 million more (woefully far from all) Americans have health care coverage, no one can now be excluded due to a pre-existing condition, the growth in health-care costs has slowed and, on balance, we seem to be a little better off than without ACA, it is clear that insurers and big pharma -- not health care "consumers" -- are the winners. All that lobbying paid off.

"Because of a failure of nerve and the immense power of health-care stakeholders, the A.C.A. has reinforced and accelerated many of the system’s most toxic features."

We still need single-payer.

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Cool
clear
Brooke

July 31, 2015 -- My favorite podcast, On the Media, yesterday delivered an incisive and scathing look at the way health and diet news is reported in popular media, popping many bubbles of conventional wisdom. Its anchor Brooke Gladstone (this week without her equally brilliant and wry co-anchor Bob Garfield) subtitles this piece, "High colonics, vampire facials, and the magical thinking that fuels an industry."

Ms Gladstone righteously and accurately excoriates, as an example of the irresponsible and sensationalist writing that passes for journalism, an article that proclaims that kale is actually bad for us, describing it as "stunningly unsubstantiated." This is just one article in an endless parade, she tells us, that trumpet the newest food "breakthrough" or "medical miracle" or "first of its kind" or "game changer" or "new standard of care" that will kill us or save us. Other examples are omega-3s, dark chocolate, red wine, cell phone radiation, yo-yo dieting, and don't get her started on gluten.

She cites a genuine expert regarding gluten and the diet craze that now surrounds it. For people who don't have a diagnosed case of celiac disease (i.e. more than 99% of us), clinical trials have found no benefit in avoiding these foods. The popular frenzy that now surrounds supposed gluten-sensitivities is just the latest example of the effectiveness of the pop science press.

She further reports that there is no such thing as a "simple screening test." If a story claims this, run for the hills! Screening test decisions should actually be among the most complex that we face in all of our health care decision-making. What will we do with the results? It is very difficult to ignore a positive, even when the treatment decision that seems inevitable does more harm than good.

She warns us not to confuse -- as many such articles would have us do -- risk factors with actual diseases. The classic example is LDL cholesterol and heart disease. The public has fixated on their serum cholesterol numbers instead of on the numbers that really matter: the rates of death from heart disease. Beware, she further exhorts us, of the representation of normal conditions such as baldness by the "disease-mongerers" as pathologies. In all these cases, the objective is, of course, to drive spending with fear.

Of the numerous myths she debunks, my favorite is the one about drinking eight glasses of water a day. It's just not true. There is no evidence that all this water, as Jennifer Anniston has claimed (in an example of what is termed marketing by celebrity culture) will make your skin glow. Drink water when you're thirsty. That's all you need.

How do these stories come to be? Ms Gladstone interviewed John Bohannon of Science magazine who describes their typical trajectory: launch a study of some popular food or behavior, "...do a bad job with the statistics and the design of the experiment, get a bad paper published, and then build a global multimedia campaign around it... There are diet fads that come like tsunamis every few months. Why have journalists missed this?" Well, Ms Gladstone hasn't and I am grateful for her rare, honest voice.

Here is her Skeptic's Guide to Health News and Diet Fads.

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Interopera-
wha?

June, 2015 -- My friend and former classmate, the highly accomplished Dr. George Krucik laments the ACA's failure to demand interoperability among healthcare data software vendors and systems. You got that right, George!

Indeed, Meaningful Use fails to call for EHR interoperability -- a serious omission. However, it does call for specific types of data to be exchanged between specific types of providers.

For example, deservedly-maligned patient portals (that I've blogged about) will be required to share certain data such as lab results with patients and with the ordering providers.

Medication reconciliations will be required to be shared among providers.

Hospital discharge information is to be reported to third parties (payers, mainly).

And there are a few more dribs and drabs of data that must be captured and shared.

These are baby steps but that's as fast as our industry can go. Keep pushing, George!

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Defending
their
turf

June, 2015 -- So it's data silos not missile silos but both provide formidable defense. For the EHR vendors, one way to defend their turf is to not share their data. In other words, with data silos.

Bad news for the FHIR folks. No EHR vendor will expose all their data fields to any public API (Application Programming Interface). This will make it hard for people like me to build useful medical apps.

It's a deadly blow to any notion of medical data access and sharing, and ought to have been forbidden by the ACA...

Oops, bad oversight!

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Dentist
regent

May 22, 2015 -- As a member of the committee that chose him, I am proud to announce the selection of Harvey Brody, DDS, our next alumni regent. He is the first dentist to serve as a regent of the University of California.

The announcement is here.

The last alumni regent from UCSF (2007-2009) was Dave Shewmake. Like me, Dave was a graduate of the Medical Information Science Section of UCSF's Graduate Division. Serving as a regent was one of Dave's peak experiences, as it will no doubt be for Harvey.

Congratulations, Harvey!

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Woulda shoulda

May 2015 -- In his brand new (May 2015) book, The Digital Doctor (about which I will blog in detail soon), Chair of UCSF's Department of Medicine Dr. Robert Wachter reports David Brailer's (G. W. Bush's healthcare technology czar) comments on the ambitious Health Information Technology for Economic and Clinical Health (HITECH) program. I think Brailer nailed it.

He told Wachter that "HITECH locked in an existing set of clunky products and led the computer vendors to focus on meeting federal requirements [Meaningful Use] rather than innovating" (p. 18). Existing vendor hegemonies (especially Epic) were thus strengthened by the financial pressure on provider organizations (especially hospitals) to hurry up and computerize, regardless of quality.

Instead, Brailer says, HITECH should have spent its $30 billion (yes, with a B) on:

  • standards,
  • interoperability,
  • a "Geek Squad" to help with training and implementation, and
  • creating a cloud-based "medical Internet".

Perhaps Wachter, Brailer, and other visionaries can guide us in a more productive direction.

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Nursing volunteer

May 18, 2015 -- Considering volunteer nursing in a distant disaster zone? Fellow UCSF grad Joe Niemczura is doing this in earthquake-stricken Nepal and writes an excellent blog. Squat toilets, "water discipline", modest dress, and cultural sensitivity are just the beginning.

Kudos to you, Joe, a volunteer nurse sharing "your gift to the world."

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Military nurses

May 13, 2015 -- A new hero! This (unnamed) nurse at Guantanamo Bay, Cuba, refused to force-feed detainees. As is plainly visible to everyone but the willfully blind, doing so would have violated the code of ethics we nurses swear to. Read about it in Military Times.

This sheds new light on the world's most powerful military, regulated at least a little by ethics and humanity. If you are looking at nursing career options, consider What's Inside a Military Nurse's Toolkit? and take hope from our new nurse hero.

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Overkill

May 11, 2015 -- In today's New Yorker, Dr. Atul Gawande hits yet another home run: "Overkill -- An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?" He writes:

[We have] a new, unanticipated problem: ...the correct diagnosis of a disease that is never going to bother you in your lifetime. We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, and catch those diseases early, we’ll be able to treat them before they get dangerously advanced, and save lives in large numbers. But it hasn’t turned out that way. For instance, cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted... [emphasis mine]

The medical system [does] what it so often does: tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk. Meanwhile, we avoid taking adequate care of the biggest problems that people face -- problems like diabetes, high blood pressure, or any number of less technologically intensive conditions. An entire health-care system has been devoted to this game. Yet [with the ACA and new standards of practice] we’re finally seeing evidence that the system can change.

He also follows up on a shocker he wrote five years ago, discussed here. He described the skewed incentives and thus excessive costs caused by our fee-for-service payment model, gradually being phased out thanks largely to an outcomes-and-quality-based model mandated by Obamacare.

Thanks, Dr. Gawande, for giving us new hope!

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BANIA

April, 2015 -- Here is the actual survey referenced by my earlier blog, HIMSS and HERSS. Entitled 2015 HIMSS Impact of the Informatics Nurse Survey, it concludes that informatics nurses are useful.

We are also organized! Here in the San Francisco Bay Area, we are starting up the Bay Area Nursing Informatics Association (BANIA), our local chapter of the national American Nursing Informatics Association (ANIA).

Join us!

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World domination

April, 2015 -- At HIMSS15 I saw world domination and this is what it looks like: the biggest trade show booth you ever saw! Seemed like acres! Why is that scary?

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HIMSS and HERSS

April 15, 2015 -- My newest nurse hero: Patricia Sengstack DNP, RN-BC, CPHIMS. At HIMSS15 in a presentation (like me, Patty was in the audience) about Continuity of Care, we were shown a diagram of the organizational structure that implements it. The box labeled Management Team contained only CMO/CMIO. That’s code for "doctors run the show." Oh my! Patty leapt in: "Excuse me, please attend Informatics 101: you need CNO/CNIO in that box, too!"

There is no excuse for omitting RNs from the IT implementation teams for EMRs and other tech that impacts our work. It is indeed Informatics 101... And so many have yet to learn it.

There’s plenty of supporting evidence, for example regarding a hot topic today, population health: a survey showed that some people think that nurses are actually useful when implementing HIT. "60 percent of respondents feel that informatics nurses play a key role..." Nurses are useful? Who knew?

But what about those other 40%? What are those folks thinking? Have they ever met a nurse? How about a nurse informaticist? We in this job role must be from Mars. Can we trust this report? After all, nobody uses EMRs more than do nurses... Not even close. Do you suppose heavy usage entitles us to claim some expertise? Might we possibly be what these C-level folks call stakeholders?

Hello, world? Listen to Patty!

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HIMSS15

April 14, 2015 -- I spent a fascinating week in Chicago attending HIMSS15, a healthcare technology show. There were 38,000 of us; the scale was immense. And so are the dollars in this industry. Each day ended with a parade of black Escalades ferrying the assorted C-level types from the convention center to their hotel suites. Is this what -- in healthcare -- we have become? Is it what we want to be?

Among the Armani suits were health insurance executives. Bruce Broussard, CEO of Humana was one of the keynote speakers. He talked about "responding to consumers’ wants and needs." Evidently, insurance people must create the illusion that they add value.

The first fallacy is that their relationship with patients is -- by definition -- anything but adversarial. They do their job "best" when they deny care, because the constituency they serve is not actually patients. Humana is a corporation; its primary purpose is to serve -- again, by definition -- its stockholders. There is nothing wrong with that; it’s how capitalism works. Why pretend otherwise?

The second fallacy is that patients are the consumers. The definition of a consumer is one who makes a purchasing decision; one who is the target of advertising and sales. In health care, that’s mostly doctors. The doctor chooses the drugs, the treatments, the procedures. It’s mostly the doctors who are wooed by pharma and device manufacturers. A tiny portion of those advertisements are patient-directed (and some would argue that this shouldn’t be permitted) e.g. sleeping pill ads on TV. Let's not pretend that patients are more than pawns in a high-stakes game played between medical vendors, payers, and the real consumers.

Broussard arrived by private jet. He describes Humana as "one of the nation’s largest health and well-being companies." He is a master of euphemism. Indeed, his entire industry is. Do they add value? Quite the opposite! But I guess this doublethink enables them to sleep at night.

He showed us some slick, highly-produced videos of happy Humana customers, and recited drivel -- larded with folksy homilies -- about making consumers happy and healthy, some self-serving statistics about excess care delivery (we overspend on all our lucky customers), the ineptitude of Federal programs (only private companies like ours are capable of delivering decent care), and litanies -- now de rigeur -- about the need for change. All delivered with conviction and stage management, supremely polished. No mention of his bloated paycheck. Despite lots of brave talk about embracing change, that is surely the thing he wants least.

More than ever, it’s clear to me that these parasites must go. They add no value. They are blood suckers, singing love songs while we bleed. Single payer is the only way forward.

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Patient-centric?

April, 2015 -- We speak of being patient-centric and of patient engagement but still fail to give the patient control of their data. The provider institutions remain in control and responsible for stewardship of the data. Incentives for silo-ing remain in place.

Meaningful use mandates some data sharing but vendors and providers do this only begrudgingly. The value to patients of "portals" could be much better but the incentives are not there for those in our community who create them. For example, as a patient I have not seen even a single provider portal that would tell me what some service would cost. Nor has any patient portal ever asked me whom I might want to withhold any of my data from or disclose it to. We are a long way from being patient-centric.

To be fair, these shortcomings are not the fault of the system developers nor even of the health care providers. Rather, it is the financial incentives here in the USA that force them to be counterproductive. The Meaningful Use features of the Affordable Care Act will soon require providers and developers to share some small portions of their data with each other and with patients but we are a long way from giving patients control.

All this talk of being patient-centric is hot air. Only Meaningful Use Stage 3 will cause that to change. Money is the driver in every system but few channel it as perversely as we do. Big pharma, insurance companies, doctors, hospitals, labs and other ancillary service providers make money by selling products and services -- the more and the more complex the better. Our health care system does not exist primarily to serve patients, and the new legislation does only slightly more than nothing to improve that. Too bad for America!

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We've come a long way...

April, 2015 -- Check out the "Aristocrat of Uniforms" (what the well-dressed nurse wore in the 1920s) at UCSF's archive.

Very elegant but I'll stick with my scrubs, thank you!

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Pepsi Apples

April, 2015 -- "Dean Mozaffarian," writes pundit Jason Clark, "is a well known nutritionist and Dean of the Friedman School at Tufts. He proposes taxes on unhealthful foods and drink and subsidies on the healthful ones: Should we tax unhealthy foods?"

Jason continues,

Trouble is, I don't think he goes far enough in his analysis. I have no problem with 5 cent apples (though that would require planting a lot more apple trees, which would cut into grain production), but I think 25 cent salmon filets would be detrimental to the environment. Fish is not a sustainable major protein source for 7 billion people, and there are problems with farmed salmon (e.g. dioxin). While salmon is no doubt more healthful than red meat, there is probably contamination, and it is environmentally a non-starter.

Why can't the 'big thinkers' truly consider the big picture? A world of 7 billion needs to subsist on unrefined grain, vegetables, and smaller amounts of fruit, beans, nuts, seeds, etc. Animal products should not be subsidized and should be eaten much less or not at all. Clearly, Mozaffarian feels he needs to appeal to the 'flesh lobby', even if it's fish.

He doesn't answer the question of why apples often cost more than hamburgers in America. Clearly, meat is subsidized, while generating tremendous external costs borne by the environment and healthcare.

We wholeheartedly agree.

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Counting

January 30, 2015 -- Last night from 7 pm until almost midnight, with one of several dozen teams of three volunteers, I traveled every block in a prescribed area of the Mission District for San Francisco's annual point-in-time homeless count.

We need a census of these folks not only to grasp the magnitude of that population but also for federal funding for programs that provide assistance allocated on a per-capita basis.

Most major American cities conduct these studies but San Francisco is one of few that does so almost entirely by volunteer workers. I am proud of my City and how we care about and for all our residents, even those who sleep on streets and in parks.

In the approximately 30-block area our team covered, we spotted fifteen people in sleeping bags or blankets on sidewalks, under staircases, or in makeshift shelters in parking lots. That's fifteen too many, but it's a start.

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New
Guy

January 15, 2015 -- In the 70s and 80s, UCSF was a leader in Medical Informatics. My department there, called Section on Medical Information Science, did groundbreaking work. For example, my master's thesis was an electronic medical record -- one of the first -- that I developed from the ground up, and deployed and tested in a live setting, UCSF's Dermatology Clinic. It worked fine!

Perhaps the most important work being done in our Section at that time was the development of medical terminologies, lead by our Chairman, Dr. Marsden Scott Blois. With his passing in 1988, our Section lost its funding that had come primarily from the National Library of Medicine. Many of our faculty and graduates defected to Stanford where a growing bioinformatics department picked up the leadership ball.

Today's news signals new hope for retaking our rightful leadership position. With the hiring of Dr. Butte (pronounced "beaut" as in "beautiful") and the reconstitution of our Section under the name "Institute for Computational Health Sciences," UCSF stands to resume its premier position in this area.

My concern is that amid the flurry of buzzwords -- "big data", "bioinformatics", "genomics", "precision medicine" -- we not lose sight of the central part of our mandate, clinical care. An essential tool for clinical care is the electronic medical record. Though in the last few years (driven especially by the incentives of Obamacare's Meaningful Use) this technology has become widely deployed, we are still not very good it. It is not mature. There is much work that remains to be done, and it is my fervent hope that much of it will be done at UCSF.

I mentioned this when I recently met with Dr. Butte. He agreed. This could be the "re-dawning" of an important era at UCSF. Welcome Dr. Butte!

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Project
Homeless
Connect
57

December 17, 2014 -- Our 57th Project Homeless Connect event.

As always, we provided an amazing range of services. I was part of the nursing team, taking vital signs, triaging, interviewing and diagnosing. A lot of suffering. Some very, very sick people. Sometimes shocking, always sobering.

My photo is of Gavin Newsom rallying the "troops".

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Supes
vs
soda

December 10, 2014 -- Tonight we celebrated our near-victory in San Francisco over Big Soda. (I have blogged about the battle here, here, here, here and here.)

Spending $3 for each yes vote, we actually got a majority -- 56% -- versus the $100 that Big Soda spent for each no vote. Alas, because it was to have been a targeted tax (a quirk in our City's electoral system) 66% was required.

I do believe that it is an appropriate role for government to protect citizens from threats both external (national security) and internal (e.g. high-risk behaviors). Libertarians would likely agree with the former but not the latter... until it regards something they need, e.g. clean air and water, safe products, etc. Sweetened drinks are not a safe product.

So how does government do this?

  • Laws (e.g. seat belts -- thoroughly proven to save lives)
  • Education (e.g. sex ed in schools -- thoroughly proven to reduce risky behaviors)
  • Taxation (e.g. tobacco taxes reduce smoking thus saves lives)

I do have some intelligent friends who nonetheless opposed Prop. E calling it an overreach of the nanny state. I disagree. Taxing sweetened drinks would function as do tobacco taxes and tobacco education in schools.

It is the right thing to do!

Present at our celebration and spearheading the effort to pass this innovative legislation were (L to R in my photo) Supervisors Malia Cohen, Eric Mar, and Scott Wiener. How often can we say we are truly proud of our leadership?

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23
and
Anne

December 9, 2014 -- I have lots of heroes. My newest is Anne Wojcicki, one of the panelists at the Technology Advisory Group meeting I attended today. She is the co-founder and CEO of 23andMe, the company that, for $99, will sequence your DNA from a saliva sample and would (if it were permitted) tell you a lot about your genetics, your ancestry, and predispositions for a variety of traits and conditions.

Alas, the FDA shut them down citing the potential for inaccurate results. The main problem is a regulatory system that cannot keep pace with innovation. By definition, regulators are a step behind and in cases like this one it is to our detriment. We do need regulation to keep us safe from snake oil but the delicate balance between that and new technology sometimes eludes us. As Ms. Wojcicki explained it, each of the genes for which her company tests is considered by FDA rules to be a distinct diagnostic product. 23andMe would have had to apply for literally millions of product licenses. Instead they went belly-up.

When it was still in business, 23andMe sold a commoditized version of the precision medicine Sam Hawgood (see below) talked about. Indeed, Ms. Wojcicki's vision was to liberate genetics from the research lab and create a consumer revolution. "Who owns the data?" she asked. This would have enabled us each to possess our own.

Another obstacle was the all too familiar one of reimbursements. Though genetic information has the potential to make health care more effective, insurers will not reimburse for tests like these. Like the regulators, they are behind the times and the quality of our health outcomes suffers as a result. Ms. Wojcicki quoted an MD at a conference: "The biggest problem with 23andMe is you generate non-billable questions."

How do we get regulation and reimbursement to catch up with technology and with the public good? Perhaps nobody knows the complete answer but some good people are working on it. Go Anne!

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Pride
and
precision

December 9, 2014 -- Today I attended a UCSF event named Technology Advisory Group. It was chaired by Sam Hawgood, our new Chancellor. He touted precision medicine, an area of research (and eventually a strategy for delivering healthcare) that is genomics-based. UCSF is a leader in this research.

What is precision medicine? My simplistic understanding is that the effectiveness of certain treatments -- especially in oncology -- is in large part determined by our genetics. Precision medicine would take a patient's genetic predispositions into account, for example, when planning a course of chemotherapy.

I'm proud of the industry-leading research at my alma mater!

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Playing
with FHIR

November 2014 -- One of the things I learned at AMIA's 2014 conference is that a thing named FHIR will change the way we do computing in healthcare.

Much of the communication that is done between the numerous and disparate software systems that run our hospitals, labs, clinics, payers, etc., etc. is via an antique and under-powered standard named Health Level 7 (HL7). Standardized communication protocols were a breakthrough in their day but that day was decades ago. FHIR is HL7's effort to remain relevant. It just may work.

Today's massive, monolithic, and preposterously expensive EMRs and EHRs will, they claim, with time become relegated to commodity products serving as backend servers of medical and financial data, living in server farms in basements or even in the cloud. The front ends (the part users see) will be small, cheap, easily-deployed (and replaced) apps. Everybody is talking about apps.

Modularity in healthcare software has been predicted for many years yet no one has been able to make it work. The contrarian view -- and it is thus far proven by practice -- is that the data and the workflows are just too complex, and that's why our only choice is the fabulously complex and expensive software monstrosities of today.

Who is right? Only time will tell.

By the way, one of HL7's inventors back in the 1970s and 1980s was my UCSF grad school professor Dr. Don Simborg. Go Don! Go FHIR!

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AMIA!

November 19, 2014 -- Today was the last day of the American Medical Informatics Association's 2014 conference in Washington, DC.

I learned a lot, grew professionally, enjoyed seeing what everybody else is working on and talking about what I'm working on, and shook a lot of hands.

Dr. Virginia K. Saba

Among them were legends in the field of Nursing Informatics Drs. Virginia Saba and Kathleen McCormick. Here are their autographs.

 

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Et tu,
RNs?

November 8, 2014 -- Usually the level-headed ones, now it seems even we nurses are infected by Ebola frenzy. Unlike the ignoramuses of fearmongering Fox News and its ilk, we should know better. Kaiser nurses are actually planning a strike! Nov. 12. Are Sutter nurses, too, planning anything like this?

If we really want to do what's right for our patients we wouldn't waste nursing resources on a crisis that doesn't exist. We'd wash our hands more. Things like MRSA and C-diff are real and they kill lots of people. And tens of thousands die of the flu every year. Let's urge our patients to get their shots. Half of America can't be bothered. Yet they obsess about Ebola.

Et tu, RNs? Say it isn't so!

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Wise
Cutting

October, 2014 -- I recently read and thoroughly enjoyed Dr. Abraham Verghese's 2009 bestseller Cutting for Stone. "Cutting", of course, is the slang surgeons use to describe their work.

Ethiopian-born and today practising at Stanford, Verghese shares much wisdom. For example, he recites surgery's Eleventh Commandment:

Thou shalt not operate on the day of a patient's death.
Much to think about. Much that's profound.

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Talking
Sense

October 23, 2014 -- A rare voice of reason on Ebola is that of Dr. Paul Farmer, a physician from Massachusetts, recently returned from Liberia.

Here he's interviewed by Audie Cornish on NPR. And here is his diary in the London Review of Books. Both are highly recommended.

The main takeaway is that Ebola needn't be nearly as deadly as it's been thus far; inadequate health systems are to blame. As with cholera and other hemorrhagic infectious diseases, many or even most deaths could be prevented by access to ORT (oral rehydration therapy).

Of course, the story is not that simple, but it's an important one. Thank you, Dr. Farmer, for telling it, and for talking sense amidst the babble.

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Lava
Mae

October 23, 2014 -- Today I volunteered with the Lava Mae team and their shower bus. The name is a play on the Spanish words for "wash me".

San Francisco donated an obsolete-but-serviceable city bus and Lava Mae fundraised the $75,000 it cost to convert it to a pair of showers on wheels.

Three days a week, the bus is parked in places where homeless people congregate. For many, it provides a rare opportunity to get cleaned up and feel human again. During the course of a five-hour shift, 40 or 50 people shower -- privacy, lots of hot water, castille soap, fresh towels, and friendly folks.

Sometimes the streets of San Francisco are not so harsh after all.

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Hey
Obama

October 10, 2014 -- President Obama came to San Francisco today on one of his fund-raising tours.

We let him know what we want. In no uncertain terms!

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Schmebola

October 3, 2014 -- Laurie Garrett is not the only one drumming up Ebola hysteria.

Even less rational is the drumbeat from the right-wing fear-mongers. Stephen Colbert has collected clips of insane "reporting" by Fox.

Fortunately, there are a few voices of sanity. Here is an article in which Liz Szabo sums up America’s overreaction to Ebola.

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New
Vectors

September 29, 2014 -- My friend Jason Clark observes that corporate profits continue to trump human health and wellbeing.

He writes:

Poor diet is now responsible for a greater burden of disease than smoking, at least in America. Food companies must be controlled much as tobacco companies have been. See Collaboration with the New Vectors of Disease that points out that the food industry "...may require tobacco industry-style regulation."

Banks must be controlled as well, so that we don't get a repeat of 2008 -- but I think Obama missed his chance to regulate the banks in 2009, and another financial calamity is in the cards. The last five years have been a gigantic lesson in moral hazard, whether in the USA or in Europe Union, the UK, or Japan. Central banks covered up the mistakes and fraud.

Energy use and extraction must be controlled if we are to prevent catastrophic global warming (+6℃) by the year 2100. Yet we have been moving in the wrong direction, and public skepticism in the US has actually been growing (probably due to the efforts of right wing think tanks and spending by Koch Bros. and their ilk).

So while we won the war against the tobacco companies (mostly because we didn't need to smoke), the fight against Big Food, Big Banks, and Big Energy is harder because these are less discretionary. Tobacco may be addicting for its users, but food, money, and energy are primary to any civilization.

Good luck with the soda tax.

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Teachers

September, 2014 -- Dying, my friend Heather taught me so much. I am a nurse, trained, licensed, and full of technical knowledge. I have accompanied patients toward the next world, and supported their failing, disfigured bodies en route. I know something about the inevitable sequence of events, the takeaways, the suffering.

About her cancer, Heather asked, "Is it serious?" What she wanted to hear was, "No, you'll get over it. You'll be fine." Being truthful, I said, "Yes." I wanted to add, "But there are things we can do to improve the situation." But she had already hung up the phone.

What did she teach me? The power of denial. When it's you, I can talk about it all day long. But when it's me, change the subject. I'm not going there. You can't make me. No one can make me.

The death spiral can be handled like so many others -- addiction, alcohol, violence -- spinning downward with eyes shut tight. I can be swallowed by it yet refuse to look at it. Of course, denial is one of Kubler-Ross's famous phases: "F* you, f* you all, f* the world, this isn't happening."

My father's passing in 2006 taught me a lot, too. He made it to the anger phase, or perhaps it was bargaining... Kubler-Ross is helpful but not the whole story. On his last day he said, "But I have so many projects yet to do." He was good at so many things; so much skill, wisdom, and passion for art, politics and people. All that is gone now.

My best buddy Mike on his own death bed got fully down the Kubler-Ross trajectory, all the way to the acceptance phase. He supported us around him who were falling apart, filled with grief at his impending departure. "It is what it is," he taught us.

Each died in their own way. Each taught a lesson I'll never forget.

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Ebola
Gates

September 10, 2014 -- The Bill and Melinda Gates Foundation today announced its commitment of $50 million to support the emergency response to Ebola. At last, we are starting to see the resources this crisis demands.

Obama sought $88 million but yesterday House Republicans slashed Obama's requested Ebola funding by more than half.

What is needed for an appropriate response? In an article today entitled Ebola Then and Now, Drs. Breman and Johnson in the NEJM say,

...the main priorities should be adequate staff for rigorous identification, surveillance, and care of patients and primary contacts; strict isolation of patients; good clinical care; and rapid, culturally sensitive disposal of infectious cadavers... We also await key virologic, clinical, epidemiologic, and anthropologic descriptions of the epidemic.

We hope that this money from Gates and whatever slips past the Washington partisans will make these things happen.

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Ebola
death

September 3, 2014 -- We have seen another tragic death of a healthcare worker in Liberia, Dr. Sam Brisbane, the Emergency Department chief in the only Monrovia hospital that accepts Ebola patients. The doctors and nurses are paying the ultimate price. In another heart-wrenching NEJM article, A Good Death -- Ebola and Sacrifice the authors debate the limits of their "duty of care toward their patients."

And here (Sept. 5) is another story, A Diplomat Infects A Doctor As Ebola Spreads In Nigeria. The diplomat violated a quarantine order and now "[authorities are] not optimistic about the Nigerians' ability to contain Ebola as it spreads beyond Lagos."

You can track the spread of this and other diseases on Healthmap, a global disease-tracking service directed by epidemiologist John Brownstein of Harvard University. Here is their tracking of ebola. Press the Play button to see how the disease has progressed numerically and geographically over recent months.

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Corporate
genetics

August 29, 2014 -- If you're not already a vegetarian, you've probably at least considered it. One of many reasons is ethical, both for the animal treatment and for the industrial genetics, controlled by just a few corporate giants.

Here's a way to eat eggs and chicken (and help propel a movement) that's more friendly to the environment, to the animals, and to our bodies. It's described in today's National Geographic: Open-Sourcing Chicken: Breaking Free from Corporate Genetics by Maryn McKenna.

It's part of community-supported agriculture. My family has enjoyed Eatwell Farm's weekly food basket for years. Pictured above is Eatwell's proprietor, Nigel Walker. Consider his basket (delivered in San Francisco) for your own household, and the crowdfunding campaign for the planet.

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A
nurse
hero

August 29, 2014 -- The Ebola crisis worsens. Hopes for at least one vaccine (from a San Diego company) are dwindling. The number of reported cases exceeds 3,500. More than 1,900 have died in Guinea, Liberia, Nigeria and Sierra Leone. Senegal reported its first confirmed case today.

"The current outbreak is in both the anglophone and francophone countries, with associated transmission risk implications," writes epidemiologist Pat Olson MD. "This is the only disease I'm aware of historically where the caregivers are specifically identified as those at highest risk." HuffPo: "Deaths Of Ebola Researchers Underscore Urgency Of Their Mission".

One of the heroes is RN Anja Wolz, author of Face to Face with Ebola -- An Emergency Care Center in Sierra Leone in NEJM. She volunteers as a nurse and emergency coordinator for the Médecins sans Frontières (MSF -- Doctors Without Borders). She writes,

Everyone working in the isolation area must follow the protocols and procedures to the letter... one mistake could be deadly.

She continues,

The new patients sometimes arrive eight to an ambulance... We've given the ambulance drivers basic PPE (personal protective equipment) to distribute to patients, but they're afraid to get close enough to hand it out... The global health community has taken a long time to react... We need to be one step ahead of this outbreak, but right now we are five steps behind.

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Talking
soda
tax

August, 2014 -- Last weekend I helped staff a sidewalk table at a farmer's market. We harangued the passersby. Some brushed us off. Most were polite and surprisingly well-informed on nutrition. For those who weren't, here were our talking points.

Health Issues

  • Soda is the largest source of sugar in the American diet.
  • Liquid sweeteners disrupt bodily metabolism. The liver processes them differently than it does solid sugars. Eventually this leads to diabetes.
  • We have an epidemic of diabetes.

Legislative Issues

  • Purposes of the tax: 1. Reduce consumption, 2. Raise $31M (est.)
  • Use of funds (earmarks):
    25% public health
    40% school district
    25% parks and rec
    10% special projects related to nutrition education, PE classes, etc.
  • Only drinks with added sweeteners are taxed. Not fruit juices.
  • The tax will be collected at distribution, not at retail sales, so grocery stores will be unaffected.

Election Issues

  • It's a "special" tax -- earmarked, not for the general fund. We know exactly how it will be spent.
  • Special taxes require 66% of the vote, not just 50%+1
  • Our opponent, the Coalition for an Affordable City, is funded entirely by the American Beverage Association. Their canvassers and operatives are paid. Ours are volunteers.
  • The argument that this is a regressive tax ignores the fact that diabetes is a regressive disease. Both soda advertising and sales and diabetes are concentrated in low-income neighborhoods.

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Ebola
hysteria

August 14, 2014 -- (an open letter) -- I'm disappointed, Laurie Garrett! As a Pulitzer prizewinning journalist and one I have heard and respected on NPR (and a fellow UCSC alumna, too) you appear now to resort to crass sensationalism.

In an article entitled You Are Not Nearly Scared Enough About Ebola in Foreign Policy's online magazine, you write things like, "Wake up, fools." That is inflammatory language and does not befit serious journalism. Worse, you appear to conflate (surely on purpose; you are too smart not to know the difference) the severity with the communicability of a disease.

Even Fox News takes a more reasoned approach to this topic (Gutfield: Stop the Ebola Hysteria).

Here's what the experts say about Ebola: While it's true that the majority of those who catch Ebola die, it's also true that it's hard to catch. The period during which the disease is communicable is while the patient is actively symptomatic and postmortem (the big problem with funerary rites). These are not times during which the patient is likely to travel or even get out of bed. It doesn't have a long, silent incubation like, say, AIDS; recent evidence shows it to be three weeks. It's not airborne. It's communicated only by direct contact with body fluids.

Reading your article carefully, I see that it doesn't actually contradict these facts. However, its tone is sensationalist or worse. Is your intent to frighten? I am surprised to see you stoop so, and the same for Foreign Policy, though evidently its mission is to "question commonplace views" (see Wikipedia) and, I guess, provoke debate. But this is irresponsible.

Please cool the rhetoric. Stick to the facts. The crisis is real but creating panic does no one any good.

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A garden
to tend

August 2014 -- I recently read Dr. Victoria Sweet's 2012 recounting of her twenty years at San Francisco's venerable Laguna Honda rehabilitation center, recently transformed from almshouse (the last one in America) to hospital.

Her book is entitled God's Hotel, and subtitled, "A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine".

The New York Times entitled its review, A Hospital That Gave Its Patients Time to Heal.

It's a fascinating concept, rare in today's healthcare system in which the body is an engine to repair... As quickly as possible, and at the lowest cost.

Dr. Sweet suggests that -- just as an almhouse is an old and alas discredited model -- an old metaphor, similarly worthy of revival, is of the body as a garden to tend. She calls it slow medicine.

Almshouses and gardens to be lovingly and patiently tended... Dr. Sweet gives us pause.

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Medicare
for
all

July 2014 -- Another hero! Michigan's Congressman John Conyers has reintroduced House of Representatives Bill HR 676, known as Medicare for All.

It would establish a long-overdue single-payer healthcare system in this country, along with several more much-needed reforms.

Its chances of passage? Zero. But it is the right thing to do. We mustn't give up. Go Rep. Conyers!

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Back
in
the
saddle

July 2014 -- For three days in mid-July, I shadowed an RN in Kaiser's Richmond, CA Emergency Department (ED). Having done my RN preceptorship in another Kaiser ED (South San Francisco), it was good to be back in the saddle.

Emergency Departments serve a variety of unique purposes in our complex healthcare system. Here are a couple of observations about that.

  • The ED is an essential portal to the hospital, admitting more than half of its inpatients. Thus, its diagnostic and triage functions must be finely honed. It serves as a gatekeeper for services that are often hugely expensive. Decisions are made here that are both medically and economically impactful.
  • It is the only place in our healthcare system that is obliged to deliver care without regard to a patient's ability to pay. This is mandated by the Federal 1986 Emergency Medical Treatment & Labor Act (EMTALA) Act. As a result, the ED often serves as the sole provider of primary care for the medically indigent.

These are onerous demands yet at Richmond Kaiser they are skillfully performed day after day. Thank you, Kaiser, for another excellent experience!

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Astro
Truth

July 2014 -- We are grateful to our San Francisco Supervisor Scott Wiener for District 8, where I live. He is a staunch supporter of the proposed "soda tax" about which I have written here, here and here. Thanks to his support, this proposal will be on November's ballot in our enlightened City.

The toll of diabetes Meanwhile, our opponent -- Big Soda -- is mounting a deceptive yet well-funded "astroturf" (pseudo-grassroots) campaign decrying the high cost of living here. Taxing sweetened drinks, they say, makes our City even more expensive. Their brochure's headline is about high housing costs, a real problem, but has nothing to do with the poisons they sell to our children.

More than half of the metabolism-disrupting sugars ingested by children come from sweetened drinks. Regarding the high cost of the lifetimes of diabetes these products cause they are deathly silent.

Thank you, Supervisor Wiener, for telling the truth despite the astroturf.

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Health news

July 15, 2014 -- Today I attended a tour of the newsroom of our local paper, the San Francisco Chronicle. It was wonderful to see -- live and in person -- the celebrity columnists we've been reading for all these years. (If only we could resurrect Herb Caen.) We also saw the news team decide what would be in tomorrow's paper... and tomorrow there it will be!

For the purposes of this blog, I'd like to point out the Chronicle's excellent, weekly Health section -- "exclusive, comprehensive coverage of health and medicine news, medical developments and studies, biotechnology, genetics, diet, fitness, and exercise trends."

Go Chron!

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Meaningful Use
Phase 2

July 2014 -- As the second phase of the Meaningful Use (MU) section of the Affordable Care Act (ACA) kicks in, we may at last be bringing under control one of the major culprits for the high cost of health care. MU Phase 2 is doing this by shifting from fee-for-service to pay-for-quality reimbursement models.

Background:

  • Meaningful Use is described here.
  • The skewed incentives (and thus excessive costs) caused by fee-for-service are described here.
  • The effect of these problems is described in a beautifully-written New Yorker story by Dr. Atul Gawande, The Cost Conundrum.

One of ACA's promises is to control health care costs. That promise is starting to bear fruit now. We are watching!

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Save
VistA

July 2, 2014 -- I have written about VistA before, and it's time to revisit it, prompted by Paul Berlin's The VA Waitlist Fiasco: VistA should not be thrown out with the bathwater.

See also Mr. Longman's testimony before Congress (linked in Mr. Berlin's article) that faults not the quality of the health care provided by the VA but rather the barriers to access to it.

Similarly, the VA's VistA EHR deserves none of the blame game being played by opportunistic media and cynical politicians. On the contrary, the rest of the Health Information Technology (HIT) industry would do well -- indeed should be obliged by legislation and thoughtfully-crafted financial incentives -- to follow VistA's example.

This would include respecting and implementing data-sharing standards (rather than the silos created and defended by self-serving vendors) and the software quality and longevity that can happen when computer code is open-sourced. VistA has done these things and should be held up as a model for the rest of the industry, not, as Mr. Berlin quips, "thrown out with the bathwater."

This is an important message and I hope the buyers and decision-makers don't just blindly make the "safe" choices as, decades ago, it was said that, "You won't get fired for buying IBM." Where did that get us?

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Apple
Health

July 1, 2014 -- Last month Apple announced its inevitable foray into the healthcare arena. It's a market too big to ignore. The first product is Healthkit.

The visible part of Apple's strategy is on the consumer side. This side is perplexing; a few years ago I thought that Google Health would be a winner but it fizzled. Will Apple succeed where Google, Microsoft, and others haven’t?

Joseph Kvedar of Connected Health offers an interesting perspective, My Wish List for Apple’s HealthKit Initiative. He says that Apple's strength is design and its weakness is analytics. Both are necessary to thrive in this market; Apple's success is not guaranteed.

Another question regards the provider side. Most of the doctors and nurses I know use iOS not Android (but this is anecdotal only -- no flames, please!) What I’d like to know is, what are Apple’s plans for this audience?

I have worked on a product for the provider side, gambling on iOS as the platform of choice, and have built NurseMind, an iOS-based checklist app for nurses. It is a standalone but would benefit from integration with Epic, Cerner, GE, etc. Apple could become the user-friendly front-end for us all with a larger ecosystem that supports health data of all types.

My prediction? They’re already working on it.

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Vocabulary 101:
HIT and ACA

June, 2014 -- The Affordable Care Act (ACA) has much to say about healthcare information technology (HIT). It has spawned a new vocabulary.

Few would dispute the goals of the ACA: quality improvement, cost reduction, wider inclusion, data sharing, and more. The buzzwords are patient-centered and value-based. The ACA also mandates:

  • Reduction of hospital readmissions
  • Improved access to critical care
  • Community and population health
  • Patient education and engagement
  • Chronic disease management
  • Preventive care
  • Payment reform
Worthy goals! But how do we get there? Here is how:
  • Meaningful Use -- incentive payments to healthcare organizations (HCOs) to acquire certified electronic health record (EHR) technology, and to implement it in three stages over a period of years with measurable goals including effective patient data capture and sharing
  • Rural healthcare -- through loans and grants for facilities and technology especially telemedicine, ACA addresses some needs of a long-neglected population
  • Behavioral health -- community mental health centers, psychiatric hospitals, clinical social workers, and others who treat substance and alcohol abuse, suicide and psychological distress, can benefit from EHRs and HIT
  • Strategic planning -- especially coordination of public and private efforts to implement HIT
  • Federal and state coordination -- focusing primarily on consistent implementation of privacy and security that at present vary widely among the states
  • Clinical decision support (CDS) -- HIT can help clinicians be more effective (though it cannot replace them) through alerts, reminders, guidelines, condition-specific order sets and eventually evidence-based practice (that ACA calls contextually relevant reference information).
  • Data sharing (Health Information Exchange, HIE) -- today's data silos -- clinicians, labs, hospitals, pharmacies, health plans, payers and patients -- must have standards, mechanisms and incentives to communicate, and governance to enable and regulate this across geographic and organizational boundaries so that information can safely follow patients to wherever it is needed
  • Consumer eHealth -- provide access to data by patients themselves, empowerment to take action and gain control over their health
  • Patient safety -- HIT has risks as well as benefits; mitigate them and prevent patient harm
  • Long-term and post-acute care -- the care of patients in these settings, especially elders, is often complicated by co-morbidities and multiple caregivers; policy can support development and implementation of HIT to support such care.
For any practitioner of HIT, this is essential vocabulary.

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End employer-provided

May 1, 2014 -- Why is your health insurance provided by your job? Why not just buy it yourself? The usual claim is that it's a perk that employees appreciate. But the real reason is that companies can deduct it from pre-tax income and individuals cannot.

Why do we have this crazy system? It is the outcome of some terrible compromises made 60 years ago, especially the 1954 decision to make employment-based health coverage tax deductible for businesses. (See e.g. this Health Policy Brief).

Today's New York Times article, Envisioning the End of Employer-Provided Health Plans by Neil Irwin asks, "Why should quitting a job also mean you have to get a new health insurance plan? Why should your boss get to decide what options you have and negotiate the cost of them? Employers don't get to select our auto insurance or mortgage company, so why should health insurance be any different?"

Indeed. Now that the ACA has given us health insurance exchanges from which no one can be turned away, and subsidies for those who could not otherwise afford it, there remains only one reason to continue the present system: that tax deduction.

My opinion? Rescind this. Instead, make health insurance premiums deductible by individuals rather than by businesses. Make people buy their own insurance rather than tying it to their jobs. This would be popular. Paychecks could be increased by the amount of the employers' healthcare savings.

So I offer a modest proposal: let companies pay their employees what they would have spent on health insurance (fatter paychecks!) and let every American deduct from their pre-tax income whatever they spend on health care. The net change in revenue to the government will be zero. The net change in costs to companies will be zero. Employee mobility and choice will be enhanced.

Problem solved.

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ACA
in real life

April 16, 2014 -- This ACA thing is tricky. For many people, signing up is not so simple. Here is a fascinating account of the issues as experienced in real life: In Their Own Words: Consumers’ and Enrollment Counselors’ Experiences with Covered California, a survey released today by the California Healthcare Foundation.

Here in San Francisco we are having an interesting time with the ACA in real life, too. My friend M. ran a couple of sign-up sessions. She says,

[We] signed up J. [who] worked at [employer X] for 30+ years and was laid off. She had Cobra then her ex-husband insured her for awhile then she was a self pay. Once the ACA came into being, J. met with [us and we] signed her up!

[We] also signed up our bartender L. and her husband. L.'s husband is a taxi driver and neither of them had insurance. And now they do!

Of herself, M. writes,
I have insurance through the ACA. I was not eligible for "regular" insurance because of a pre-existing condition and had to get my insurance through MRMIP (Major Risk Medical Insurance Plan) and paid almost $800 per month. When the ACA became available, I might have been the first in line! My insurance now has no limits and while I am paying $666 per month, it is less than $800 so I am happy!

The successes speak for themselves. Let's hope the voters are listening!

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Go
San Francisco

April 16, 2014 -- Today I attended a hearing at the Board of Supervisors of the City and County of San Francisco, my home town. The topic of the hearing was a proposed new tax of $0.02/oz of sweetened beverages. As one of several dozen who expressed their viewpoints on this proposal, I spoke as a nurse, parent, and San Franciscan.

Regarding each of those roles, I said what you'd expect: that health care workers are seeing more diabetes and obesity than ever and sweetened foods are largely to blame; that we must protect the health of our children; and how proud I am to be from San Francisco where we lead the nation in forward-thinking public policy.

What shocked me was the number of red-T-shirted proponents of the opposing side. Their T-shirts called for "fairness" and their wearers packed the room. Clearly they had been drilled by "Big Soda", the corporate interests that would be harmed by reduced junk food sales. I doubt that a single one of these well-indoctrinated flunkies would have been there without some incentive (to which not one would admit). The fairness claim speaks volumes to the fact that the science of nutrition is to them a cause that's already lost. Nonetheless, they have the big dollars to confuse the voters with a barrage of advertisements. Without that, our inspired legislation would sail through.

But there's still hope. My fellow San Franciscans are a smart and principled bunch. I hope they are enough so to not be tricked when the November ballot rolls around.

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New
Model

March 25, 2014 -- A New Financial Model for Nursing

I am a nurse and an informaticist. Combining these disciplines, my mission is to equip myself and my fellow nurses with the best tools available and also with some that are yet to be created. However, the existing financial model for nursing presents a large obstacle. That must change.

The dearth of nurse-centric (my term) tools is discussed in a paper published today, mHealth's great untapped potential: Nurses. In the context of hospital finance, nurses are seen as a cost center. Compare this with doctors who "...are considered the revenue-generators and the face of the healthcare institution."

Indeed, most of what nurses do -- administer medications, deliver hygiene, nutrition, education, progress assessments, and regular activities such as charting, health status and vital signs monitoring, ambulations and surveillance -- is not directly billed. Rather, these services are bundled into the hospital's room rate. From the point of view of accounting, nursing is a cost and rarely a revenue generator. Thus, there is little incentive to equip us with the tools that would make us more effective. Instead, workflow improvements focus on making us more efficient. In other words, the "successful" hospital gets nursing done for as little money as possible.

Yet nursing is essential to health care and, done well, contributes immeasurably to the quality of outcomes. It's time for the model to change. Starving us while pushing us to get more done and to work faster can be detrimental to quality. Hence, I offer a modest proposal.

To drive health care economics to perceive nursing as worthy of investment and redesign, we must become a revenue center. Here is one way we could do that.

Much as outpatient doctor visits are billed according to a scale of simple, medium, or complex (with fees charged accordingly), the various services that nurses provide should be un-bundled and billed on a similar scale. For example, some patients require in-bed hygiene care. They (or their insurance companies) should be charged for it, on a scale of quick, medium, or lengthy. An obese patient who requires a second nurse or an assistant to position them for a bed bath would incur a higher fee for hygiene service; it is more expensive to deliver. Nursing activities are usually charted at least briefly in the medical record; this new approach would add a charge generation to an existing recorded item much like, say, a CT scan generates both medical and financial data. Like airlines that have been able to reduce ticket prices by unbundling (charging extra for) baggage handling, hospitals could reduce room rates by unbundling the nursing services that come with them.

The article states that nurses are "underappreciated... [they] are looked upon as the single largest line item on the balance sheet... hospital IT departments are focused on those and other concerns and leaving nurses to their own devices. They don't have the time or resources to deal with nurses." In other words, we nurses often don't get the tools we need because the investment would not repay itself. It would just add to our cost that is already perceived as high.

This could change. The quality of nursing -- given incentives to equip us well -- could make a huge leap forward. It's time for a new financial model for nursing.

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Too
HIPAA

March 24, 2014 -- Why should I care whether anyone knows my immunizations or can see the x-ray image of my broken foot? I don't care -- help yourself. The truth is that for me and most people, most health care data needn't be kept private. There's nothing secret or even interesting about it... Except to researchers and to my care givers. These people should have unfettered access.

Well-intentioned HIPAA safeguards create obstacles that are not justified. In practice, HIPAA reinforces data silos -- provider institutions that keep my data to themselves -- that inhibit sharing. Also, HIPAA grows the mountains of paperwork that they and I must scale whenever care is given.

Certain types of data -- psychological health and substance abuse history, for example, listed in detail here -- should indeed be protected, with access controlled solely by the patient, but this is a small fraction of health data.

The benefits of sharing data are numerous. These include the ability to conduct population-wide and epidemiological research. Famously promoting such access to and uses of this data is Google co-founder Larry Page who in this TechCrunch piece proposes that we make all health data public. Go Larry!

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Big soda spending

March 20, 2014 -- Big Soda is fighting back and spending big. It seeks to defeat San Francisco's pioneering effort to discourage consumption of sweetened drinks -- conclusively proven to have bad health effects -- with a tax.

What is it about jobs and faceless corporations that encourages the suspension of morality? How do the people who work there feel about defending products that hurt people? There's something that just switches off in their brains. Remember Big Tobacco? And the lies they told and evidence they covered up?

Big Soda is following them down the same path, and spending big to defeat us. They're buying direct mail, live calls, organizers, consultants, and even ads on Facebook (some "friends"!)

They have the money; they can confuse voters. But this is just a skirmish. Ultimately the truth will be known. The war is ours to win.

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Who
was
first?

March, 2014 -- I have touted Dr. Atul Gawande and his medical checklists in this blog. But he would be the first to point out that he wasn't the first to apply them to healthcare. That was Dr. Peter Pronovost at Johns Hopkins in 2001. The concept is summarized nicely in this 2009 New York Times article by Robin Henig, A Hospital How-To Guide that Mother Would Love.

However, it was Gawande who applied this method on an international scale, and proved that it works. Henig writes, and quotes from Gawande's Checklist Manfesto:

The study began in the spring of 2008, and the results were startling. Without adding a single piece of equipment or spending an extra dollar, all eight hospitals saw the rate of major postsurgical complications drop by 36 percent in the six months after the checklist was introduced; deaths fell by 47 percent. "In every site, introduction of the checklist had been accompanied by a substantial reduction in complications," he writes. "In seven out of eight, it was a double-digit percentage drop. This thing was real."

The point is that anyone with a complex technical job -- including nurses -- can benefit from this simple intervention. Henig writes:

...the complexities of technology in the 21st century may be best handled by the simplest solution. "We may admit that errors and oversights occur -- even devastating ones," he writes, referring here primarily to his fellow surgeons, a group not known for modesty. "But we believe our jobs are too complicated to reduce to a checklist."
We do so at our own peril or, rather, at the peril of our patients. She concludes:
What a powerful insight this is: In an age of unremitting technological complexity, where the most basic steps are too easy to overlook and where overlooking even one step can have irremediable consequences, something as primitive as... a to-do list to "get the stupid stuff right" can make a profound difference.
Are nurses victims of the same hubris? I am working to prove otherwise.

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How
we
die

March 3, 2014 -- "What is the experience of going though a heart attack? What is that like?" asks Dr. Atul Gawande in this NPR interview about Dr. Sherwin Nuland, author of the ground-breaking How We Die that de-mythologized death. Nuland died today of prostate cancer at age 83.

Gawande observes that, until recently, medical students weren't taught about death. "It was a revelation," he says. "You could be direct with people. You could tell them the truth about what happens while being humane... what it means to be a good doctor."

Read the book. And applaud these doctors who are making a real difference in how we handle that final phase.

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Big
soda

February 1, 2014 -- Today I attended a rally organized by San Francisco District 10 Supervisor Cohen to urge a tax on sweetened drinks here in our enlightened City. Overcoming opposition from a huge and well-heeled industry (billions of dollars worldwide each year) we're working to pass a $0.02/oz city surcharge on sweetened drinks (sodas, juices, sports drinks, etc.) As usual, we're ahead of the curve!

We have an epidemic of obesity and diabetes. Sweetened foods are a direct cause. Especially for kids, increasing the prices of sweetened drinks would discourage their consumption.

Part of the reason why these foods and drinks are cheap is the Federal subsidy of corn farming. The sweeteners in sodas and processed foods are made from corn. If we can't stop the subsidy, let's neutralize it with a tax. And if we can't do it nationally, let's do it locally.

This can generate $30 million annually to fund physical education and nutrition programs for San Francisco children. Stop Big Soda! Go San Francisco!

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Politics or health?

January 2014 -- It's utterly incomprehensible that some politicians could be so driven by partisan politics that they would deny health care to their citizens rather than collaborate with the opposing party. Yet it's true.

In an unrelenting effort to undermine Obamacare, 25 states have refused expanded Medicaid funding -- funding that would have made health insurance affordable for literally millions more Americans (here's who's left behind) -- to spite Obama and his health care reform. All 25 have Republican governors. Where are the calls for impeachment? Where is the outrage?

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Disaster
not

January 2014 -- Stop calling the Obamacare technology rollout a disaster! Even Obama parrots that conventional wisdom. If you're a practitioner of technology, you know that it's never like the movies, where everything new and complex works perfectly from the moment it's switched on.

The second meme, also unquestioningly accepted, is that government -- unlike private industry -- just can't seem to "do" technology (unless it's the NSA, I guess.) In fact, complex projects are complex no matter who does them, and buggy software happens in every big project, private or public.

Compounding the technical complexity was a litany of political issues that made www.healthcare.gov's specification a moving target. A difficult project becomes near-impossible when:

  • Politics dictates an unrealistic schedule, with not enough time for testing.
  • The target was moving -- they didn't even know how many (or which) states their system had to support (34, as it turned out) until quite late in the timeline.
  • The number and diversity of systems to be integrated was large -- insurance companies, state and federal databases, even the IRS -- and without standards for data exchange.
  • There were deliberate sabotage attempts by deep-pocket special interest groups whose tactics included bogus web sites to confuse and frustrate people who sought to sign up.
  • Amazingly, the project had no official budget. In an excellent article entitled How political fear was pitted against technical needs, The Washington Post says, the "...most basic reason was financial: Although the statute provided plenty of money to help states build their own insurance exchanges, it included no money for the development of a federal exchange -- and Republicans would block any funding attempts. According to one former administration official, Sebelius simply could not scrounge together enough money."

It's remarkable that it worked at all. Now, with time for testing and debugging, system performance is improving. This is actually a pretty normal technology development and release lifecycle.

This blame game is like somebody letting the air out of your tires and then calling you names because you're having trouble giving them a ride. Stop using technology as a political football, and -- ahem, Mr. Obama and everyone else -- stop calling it a disaster!

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PS -- The cartoon is by my Dad. Click it to see it full-size.

 
Wing
nuts

December 18, 2013 -- The right-wing nut jobs at Fox just don't give up. The drumbeats about Obamacare seem endless.

Yes, Obama's promise that if we like our health insurance policies we could keep them was ill-considered. He should have added, "...if they satisfy certain minimum requirements."

The surprise was that many didn't. They were junk and should never have been allowed to be sold; canceling and replacing them with honest policies is actually one of the benefits of the Obamacare legislation.

Yes, there are bad parts of this legislation, too, e.g. that it leaves in place the cash-sucking fee-for-service providers and the yet-more-cash-sucking insurance middlemen. These are discussed in other blog entries here.

It's all in how you spin it, and Fox outspins the White House. The amazing part is that people fall for it. But then, they can't spell, either.

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Heroic
senator

December 2013 -- One Senator slogs on in the campaign for single-payer health care: Bernie Sanders (D, VT).

It's inevitable because we cannot continue as we are. Under this bill we'd have health care for all, reduced costs, and more.

Want the details? Read his American Health Security Act of 2013.

And don't give up hope... Go Bernie!

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More
homeless

December 11, 2013 -- My fifth 8-hour volunteer nursing shift for Project Homeless Connect (see previous one.)

PHC 52 Results
Client visits: 1,950
Volunteers: 887
65Acupuncture Treatments
115Behavioral Health (Mental Health & Substance Abuse)
394Benefits (CAAP, SSI, CalFresh, HealthySF/SF PATH)
124California State IDs
109Dental Procedures
252Employment Visits
175Eye Exams
16,622Groceries from Food Bank (in lbs)
70Flu Shots
115Haircuts
32Hearing Tests
15, 80HIV & STI Testing, Safer Sex Education & Supplies
31Homeward Bound
1593Lunches Served
73Massage Therapy
145Medical Appointments (including us nurses)
130Needle Exchange
127Photo Portraits
131, 706Prescription Glasses, Reading Glasses
373Shelter & Housing Applications
220Sprint Phone Calls
21Wheelchair & Walker Repairs

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Nurses
next

December 7, 2013 -- Click on this tweet to see a fascinating interview with a brilliant man, Dr. Atul Gawande. He's one of my heroes, cited often on this page.

His checklists have made huge improvements in surgical outcomes, and his writings have enlightened Americans about some of the most bedeviling issues in our crazed health care system.

He describes the career he expected, centering on policy, and his subsequent unexpected fascination with surgery. My own trajectory bears small similarities, with my nursing degree and license obtained with the intention of bolstering my health IT credentials. For me the surprise was the astonishing satisfactions -- privilege! -- of working at the bedside, making differences in lives. That people are even more interesting than technology is, in retrospect, not so surprising.

In my own vastly smaller way, I hope to emulate him on the nursing side of the hospital bed. Nurses, too, can benefit from checklists (though, oddly, it's a harder problem for nurses than it is for surgeons because our checklists describe entire shifts with many patients with widely varied problems, rather than single procedures) and offer a solution named NurseMind.

And this blog -- in which I have a lot to say about nursing and health care -- is the writing side of my hoped-for Gawande-ness. Imitation, it's said, is the highest form of flattery. Dr. Gawande, please consider yourself flattered!

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Empire
emerging

December 4, 2013 -- I used to work at Mills-Peninsula Health Services (San Mateo and Burlingame) when they were independent hospitals. Alas, this is but a fond memory. I remember Alta Bates in Berkeley before it, too, was swallowed, and Children's and Saint Luke's in San Francisco likewise. The gobbling behemoth is Sutter Health, and the evidence is mounting that consolidation drives up costs.

The article linked above mentions, for example, "$20 for a codeine pill, compared with 50 cents at a pharmacy" which is not entirely evil capitalism at work, as I have expounded recently. However, Insurance Commissioner Dave Jones (discussed here) has fined Sutter an astonishing $46 million (Sutter Health hospitals agree to pay record payment in Department of Insurance lawsuit) for fraudulent anesthesia billing practices.

Besides costing us more, the consolidation trend reduces transparency of pricing. (This, too, has been the topic of one of my rants.) What do things actually cost? You're going in for your colonoscopy, say, and want to know the price tag? Good luck!

When I had mine a few years ago and phoned three different hospitals for price quotes, only one gave me a straight answer, and that was only after repeated calls, getting handed off from one person to the next, etc.

With all this consolidation and emerging empires, it will only get worse.

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Obamacare
and
me

October, 2013 -- I am in that much-discussed 10% of Americans who buy their own health care insurance. (The others get it from their employers (55%), from the government (31%), or don't have it at all (4%) [source: Wikipedia].)

A letter last week from Kaiser informed me that my health care insurance policy premium would, starting January 1st, 2014, increase by 113%. That's not a typo. It will more than double from $261/mo to $556/mo.

This raises some questions. Can I afford that? Also, I wonder whether my old policy was what Consumer Reports called junk health insurance and Mother Jones called lousy health plans. Kaiser didn't mention the Affordable Care Act ("Obamacare") but it's clear that my old plan didn't satisfy the new law's minimum standards. Kaiser had been selling me junk.

Having always regarded Kaiser as ethical and high quality, frankly, I'm surprised. The good news is that at last they are required to be so.

Nonetheless, I now find myself in a quandary. I have not yet decided how to proceed. Stick with Kaiser? Shop around? Perhaps even on the much-maligned www.healthcare.gov web site? Fortunately for us in California, we have www.coveredca.com. What to buy? How much to pay? I'm working on it. Stay tuned.

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Future
now

September 11, 2013 -- Today I shadowed the charge nurse at an eldercare clinic. I saw the future of eldercare and it is named On Lok.

It is based on common sense. First, for both quality of life and for cost control, let's "age in place", that is, stay at home. Nobody wants grim institutional corridors, lousy processed food in dining halls full of strangers, and over-sedation by sullen, underpaid flunkies.

Second, center the care around the patient. On Lok calls them participants. Nurses there nurse but they also coordinate care, much like case managers in traditional hospitals but with long-term relationships. Participants and staff get to know each other as they work together week after week, with vans bringing them to and from the clinic, home care nurses coordinating with families for medication administration and safety monitoring. A full staff of medical professionals -- a couple of doctors, three or four nurses, an occupational therapist, a physical therapist, a psychologist, a psychiatrist, and several more -- organize their schedules around the participants at the clinic rather than for their own convenience (the opposite of most health care).

And third -- perhaps this is really first -- is humanity. Staff and participants build real relationships, getting to know each other's foibles and preferences. In nursing school we were taught not to display affection for patients. At On Lok they hug.

When I'm old and near helpless, perhaps demented or otherwise reduced in function, I hope I'm fortunate enough to be cared for by such an organization. On Lok has it right.

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Get
social

September, 2013 -- Dr. Russ Cucina, who led the implementation of Apex (Epic) at UCSF says social media are here (in healthcare) to stay, and he's right! I've written about this before and here is his slide show about social networking for doctors... and why they need to get on board.


Especially good is his taxonomy of levels of participation:

  • Minimum: write, communicate, enforce a social policy
  • Intermediate: engage reactively
  • Advanced: engage proactively
  • Master: promote health and your practice

However, I have one peeve, expressed earlier: the patient portals I've seen -- and UCSF's is no exception -- have as their primary objective the goals of the institution; any benefit to the patient is almost a side effect. There is much they could do that would serve patients -- e.g. posting price lists -- but they don't, because it would not serve the institution.

Nonetheless, I applaud Dr. Cucina's technology proselytizing -- go Russ!

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Bedside
blogger

August, 2013 -- My newest hero is Pennsylvania oncology nurse and New York Times blogger Theresa Brown, RN, PhD. Her blog is named Bedside and is in the Opinionator section of the NYT. In it she wisely opines:

  • Nurse staffing ratios are clearly correlated with outcomes. "...people died... because they were in hospitals with overworked nurses."
  • Mutual respect among the members of medical care teams is essential for the safety of patients. "...the silencing of nurses inevitably creates more opportunities for error."
  • Like Dr. Atul Gawande, she decries -- in the final stages of terminal illness -- aggressive care that reduces the quality of life in the small amount of time that remains. "We need our caregivers to talk to us, ...to understand the treatment trade-offs ...about quality of life over quantity."
  • Regardless of where you stand on the importance of Constitutional rights, do not overlook the very real suffering of patients -- victims, and their families -- due to gun violence. "The talk we hear from the gun lobby is about freedom and rights, not life and death... So I have a request for proponents of unlimited access to guns. Spend some time in a trauma center and see the victims of gun violence -- the lucky survivors -- as they come in bloody and terrified. Understand that our country's blind embrace of gun rights made this violent tableau possible, and that it's playing out each day in hospitals and morgues all over the country."

When you see these things with your own eyes, theory and ideology fall away and humanity emerges. The best nurses practice a profound humanity, and Theresa Brown demonstrates this superbly.

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Homeless connect

August 14, 2013 -- This was my fourth time nurse-volunteering for this worthy cause. We make a big difference for our 5,000 homeless here in San Francisco.

The work is fascinating. It's a peek into a world much bigger than panhandlers and sleepers in doorways. Most of its denizens are invisible to us home-full (non-homeless?) folk. A surprising number of them have jobs. In their world, there is not as much misery as you might expect but of course lots of mental and physical illness. As volunteers and nurses we do what we can but the problems are deep.

Interested? Some hashtags: #phcsf #phc50

And the official website: www.projecthomelessconnect.com

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Mere apps

August, 2013 -- I recently did a demo of my NurseMind nursing checklist app for some technically-savvy people. They were not impressed.

I think the disconnect was based on the assumption -- indeed most people appear to assume this: apps should always be simple and obvious.

Certainly, there is no excuse for a poor user interface, but it is also true that serious professional tools are necessarily complex. For example, NurseMind has a "Remind Me" feature that adds a task to a checklist. It takes three screens to do this because it needs to know: 1. what task to remind about, 2. which patient it's for, and 3. what time it's due. Simple in concept, complex in implementation. The result? With all those screens, the app looks hairy, over-engineered. Yet there is no way to dumb it down without reducing its usefulness.

A corollary of the simplicity assumption: smartphones are not suitable platforms for serious professional tools. That is the obstacle I'm encountering. People expect something trivial and are put off when it isn't. Could this be an effect of McLuhan's dictum, "the medium is the message"? You wouldn't publish the Constitution on fishwrap. And perhaps you wouldn't build serious professional tools on smartphones.

My prediction? This conventional wisdom will evolve. It will become clear that smartphones are real computers and run full-powered professional application software.

Today, we are still in the early stages of this technology. The low-hanging fruit (appealing yet simple applications) is being plucked. But people like me are working on bigger problems. The development cycle is longer and acceptance is delayed, but the trend is real. Watch as it unfolds.

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Roadmap to Single-Payer

July, 2013 --

How do we get there?

  1. Pass a Law
  2. Obtain a Waiver from the Affordable Care Act
  3. Develop a Strategy to Integrate a State-Coordinated System with Medicare
  4. Integrate Medicaid and SCHIP with the State System
  5. Determine How to Deal with Workers' Compensation Health Benefits
  6. Address Other Federal Health Benefits Programs
  7. Avoid Being Struck Down on ERISA Grounds
  8. Determine How to Pay for the Unified Health Care Program

The details are here in this valuable, easy-to-read document, subtitled How States Can Escape the Clutches of the Private Health Insurance System.

In a related article entitled Single Payer movement in the era of Obamacare, Daily Kos offers this diagram of how this would look in California.

Now that we have a roadmap, let's go!

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The Inpatient
Nursing Care
Iceberg

July, 2013 --

I've been thinking a lot about what nurses do. Also about how that's paid for.

Much of what we do is not driven by orders as are diagnostic and therapeutic procedures. By orders we mean, of course, things that can be billed. Much of nursing work is not directly billed. Rather, it's paid for as part of a hospital's room rate, just as the making of your hotel room bed (maid service) is not billed separately.

This is dramatically evident when you look, for example, at what you're charged by a hospital for an aspirin. In the drugstore it's pennies, but in the hospital it costs you several dollars. Crazy!

Or is it? That aspirin is the visible tip (to use a tired metaphor) of the inpatient care iceberg. Much of that aspirin's cost is less visible: the pharmacy that stocks it, the cart that delivers it, the bar-code scanner and medication administration system that helps confirm the dosage (and the other five rights), and, especially, the nurse who gives it to you, but only after making sure you're the right patient, that this med at this time makes sense in his or her highly-trained and experienced clinical judgment, on time, with instructions as appropriate, and maybe even a smile.

One of the effects of the financial invisibility of nursing is that electronic medical records (EMRs) don't track much of what nurses do. Charts are orders-driven -- no order, no chart. Thus, EMRs cannot construct meaningful workflows nor checklists for nurses. (Fortunately, there is a solution to that problem.)

When it's done well, nursing is largely invisible but nonetheless essential. It's the main reason you're in the hospital: for nursing care. On your bill, that overpriced aspirin looks crazy. But look again, below the surface. You got a lot more than just an aspirin. And thank a nurse!

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Gimme
Data

June, 2013 -- The story is four years old but its lesson still rings true. "ePatient" Dave DeBronkart is one of those rare, self-empowered patients who took charge of his own data and saved his own life.

Healthcare data silos serve the vendors not the patients. In this YouTube video he recounts the saga of managing his near-fatal cancer by claiming his own medical data, and in this one, he "sings" the epatient rap. The rap is funny and laughter is the best medicine, but patient empowerment through access and control of data remains elusive. We can all learn from Dave.

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Simple
Dollar

May, 2013 -- Rethinking your health insurance strategy? At The Simple Dollar, blogger Trent Hamm has created a resource called financial talk for the rest of us that includes cogent explanations of health insurance options. Especially in the rapidly-changing landscape of Obamacare, concise and timely information like this is valuable and worth a look.

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Data ownership, redux

April, 2013 -- As I have discussed previously, patients do not own the medical data that is about them. The providers (the medical-industrial complex) do. I decried this state of affairs and exhorted industry to relinquish this ownership and the patient himself to take more control and involvement. However, the issue is more nuanced than that. I have investigated it further. Here is what I have learned.

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Doc-by-mail?

March 26, 2013 -- Should we communicate with our doctors by email?

Today iHealthBeat released the results of a recent Wall Street Journal survey of physicians. Results were mixed. Some said it saves time and is easier than calling on the phone. Others complained that it is inconvenient, a data security risk, and that, unlike in-person patient encounters, they are not paid for time they spend emailing.

My opinion? I think it's great. I am a Kaiser patient and Kaiser's web portal offers a mechanism for secure, online communication. I would prefer email because then I could keep copies of what's said, but it's better than nothing.

A related question: are those "patient portals" a good thing? Yes, in a limited way. It's useful to be able to look up those portions of my medical record that my provider deigns to share, and to schedule appointments without enduring phone tree misery.

But they have many flaws. They do not share data with other providers e.g. from one hospital chain to another, or to my local pharmacy. They offer me no opportunity to add data of my own such as immunizations, lab results or procedures from outside their "network". In general, their objectives are less the patient's and more the vendor's.

This could be resolved by regulatory legislation. It would require all healthcare vendors to share data. (To its credit, Obamacare does include some baby steps in that direction.) It would put the patient in control of access to that data. It would require storage and management by a neutral third party. And more...

This wish list goes way beyond mere email... I can dream, can't I?

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Biggest carriers

January 29, 2013 -- Who are the biggest health insurance carriers in California? According to today's Los Angeles Times, this $59-billion market is shared as follows:

40%Kaiser
23%Anthem Blue Cross
14%Blue Shield of California
9%Health Net
5%UnitedHealth Group

Nationwide, WellPoint is on top with 14%, UnitedHealth is second with 12%, and Kaiser is third with 10%.

How do we feel about this? As the market consolidates, we approach single-payer, which is devoutly to be wished. Also good is that some of these are non-profits; provision of health care must not be secondary to the demands of stockholders. However, without public oversight and transparency, their motivations and incentives remain murky.

Concentration of power and whopping payouts to executives of corporations -- for-profit or not -- have no place in a fair and rational health care system. Only when the system is run by publicly-selected (elected?) officials, subject to the scrutiny of we the people, and driven by no motives other than what's best for us insured, will this crazed and bloated healthcare "system" acquire a semblance of sanity and justice. We have a long way to go!

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Not a moment too soon

December 31, 2012 -- As part of its annual wrap-up of the year's events in medical care, the Medscape site offers this fascinating summary: 10 Medical Errors that Changed the Standard of Care.

We all know that hospitals are dangerous places. As I have discussed elsewhere, one of the big reasons for this is nosocomial infections (bugs you catch in hospitals). Another is errors -- things like wrong-site amputation, pressure ulcers, and medication allergies. Fascinating... and horrifying. The good news is that the industry is paying attention and making the changes that are making these errors rare. And not a moment too soon!

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Partisans

December 14, 2012 -- The New York Times reports that states with Republican governors are refusing to set up health insurance exchanges as mandated by Obama's Affordable Care Act. Why? Because they would rather see the Democratic President's Act fail than their citizens receive health care. It's partisan politics at its worst.

California has been working on its own exchange for a couple of years and it will come to life soon. It will be good for me because at last I will be able to shop around for my health insurance, comparing prices and benefits. It will be good for millions of uninsured people because, in addition to showing what's available, it will reveal what subsidies and assistance programs there are.

When people in those Republican-governor states see how their elected representatives are working against them, let's hope they vote differently -- in their own self-interest -- thenceforth. It's time to end the partisan self-destruction.

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Against the tide

December, 2012 -- San Francisco's Doctor H. J. Kim says you're better off if you don't get sick in the first place. But here's the economic undertow: treatment is more lucrative than prevention.

He's swimming against the tide... and the insurance companies. He has invested his savings in high-tech diagnostic imaging equipment (the Imatron) that enables early detection of coronary blood vessel occlusions and other pathological conditions long before they are symptomatic. This is a proven technology that goes unused because the insurance companies won't reimburse. His gamble is that patients are wiser when it comes to looking out for their own health.

A disease is easier to treat and the outcomes are better when it's caught sooner. The number one killer is heart disease. With this technology, its precursors can be detected. Millions of dollars could be saved. Most importantly, lives and suffering could be spared.

Sometimes the right thing to do is to swim against the tide.

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Scan this!

December 13, 2012 -- Today I got a Heartscan. No, there's nothing wrong with my heart (this was confirmed in the test results) but I wanted to see what this wonderful technology can do.

The machine is an Imatron and it does Electron Beam Tomography (EBT), sort of like CAT scanning but with only a tiny fraction of the CAT scanner's radiation. The study that was done on me is called Cardiac Calcium Scoring. It reveals any build-up of calcium plaque in the vessels that supply the heart muscle. This is the precursor for atherosclerosis which, with time, can occlude those vessels, starve the muscle, and cause a heart attack. Indeed, this is the most common cause of heart attacks, and heart attacks are the deadliest disease in America today.

Because the radiation is so little, you could get this test annually yet remain within FDA limits. That is a good idea for people with family history of heart disease or other risk factors. The disease could be caught before it turns deadly. Then it could be treated with radical lifestyle modification, statins, angioplasty, or whatever the cardiologist deems appropriate. The point is, prevention is always the preferable option.

There's just one little problem: insurance companies don't reimburse for this procedure. That makes no sense; you'd think they'd understand that preventing a heart attack is cheaper than treating it. But insurance company "logic" doesn't work that way. I saw this when I was a smoking cessation counselor: the insurance companies wouldn't pay for smoking cessation but somehow they were ok with paying (a whole lot more!) for lung cancer, emphysema, etc. Similarly, they won't pay for an EBT scan but they will pay to treat a heart attack... assuming the patient survives it.

Here's how that "logic" works: a dollar saved today is a dollar added to the bottom line in the current quarter. It makes them heroes because they hit their target even though it means they will pay out a hundred times as much a few years from now. Not to worry... they will deal with that when the time comes. What's best for the patient? Who cares? That's not a factor in insurers' calculations.

But it is a factor for me, and for any consumer of health care. In other words, everybody. Perhaps when we finally achieve single-payer health care financing, the short-term "logic" will at last be abandoned. In the meantime, get your Heartscan!

In the SF Bay Area:

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Being Present

September 12, 2012 -- When she was my professor at USF in 2004, Dr. DorAnne Donesky was one of the best, a clear thinker, effective communicator, and inspiring teacher. In her pathophysiology class I learned how the kidneys and the lungs work together for an astonishingly complex metabolic and chemical balance -- they do much more than pee and breathe -- one of many breakthroughs in my understanding of what goes on in my patients' bodies.

Today, Dr. Donesky articulated to me what is perhaps the central value proposition of NurseMind (I couldn't have said it better myself): it supports nurses in maintaining or even regaining their presence.

The unwary nurse can be caught up in the swirl of myriad technical tasks she must do in the course of her duties. She could devolve into a mere technician, getting the details handled but losing sight of the patient. For the aviator, the pre-flight checklist is not a how-to-fly manual but it does make sure nothing important is overlooked, and he wouldn't take off without it. Nurses need checklists no less. As the checklist lets the flyer concentrate on the skilled part of flying by tracking those details -- nothing forgotten, everything on time -- NurseMind frees up the nurse's brain (there's that word again) to concentrate on the patient, to be truly present.

Presence is to nurses what the stethoscope is to doctors: a tool without which they cannot be effective in their work. Indeed, it is perhaps more central than the stethoscope, which is used to evaluate only one aspect of a patient's health status; when she is present with her patient, the nurse's senses are freed to pay attention to everything about the patient. She attends to subtleties, and her clinical judgement is fully available to see everything that is going on -- responses to therapies, psychosocial needs, life condition. The task at hand may be cleaning a butt, but when she's present, the nurse is looking for much more: mobility, skin breakdown, level of consciousness, body systems status, disease processes, and so on.

When the nurse is distracted by work that has grown so technical, or when the "lower-level" tasks such as hygiene are given to lower-skilled workers, opportunities for this all-important presence are diminished. Though unions are not effective in communicating the importance of this tool in nursing work and the gravity of its denial, it is a big part of why nurses strike: they are frustrated by obstacles to being present for patients.

Unlike the unions, Dr. Donesky is articulate on the topic of nursing presence. As a teacher, she strives to instill it in her students and fellow nurses. It is, she says, what above all distinguishes nursing work. The surgeon performs the operation, the therapist conducts life-restoring procedures, the attending is heroic in delivering emergency care. But it is the nurse who sees the patient in between those brief doses of attention, and who is with them on the night shift and able -- when she can fulfill her presence -- to see the big picture.

She recounts the story of three bricklayers:

They labor in the hot sun, placing and cementing bricks with skill and sweat. Of his work, the first one says, "It's a job. Keeps me out of trouble!" The second one says, "It's more than a job, it feeds my family and secures my place in my community." But the third one says, "Look at the fabulous cathedral that's rising on this spot!"

Not losing sight of the central purpose of the work is this all-important notion of presence. That's the nurse Dr. Donesky inspires me to be.

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UCSF's APeX Go-Live

June 4-8, 2012 -- APeX = Advancing Patient-Centered Excellence = UCSF's implementation of the Epic electronic medical record.

This go-live is like changing the engines on an airplane in flight. Its objectives are ambitious and important -- to at last free health workers and providers from paper charts. The information flows that underlie every step of every function are being changed. The impacts on workflows are ubiquitous and profound. In this vast complex of hospitals and clinics, everyone's job is changing. Yet through it all, the beds are occupied, lobbies and corridors are bustling as always, and labs, pharmacies, radiology and imaging units, and other ancillary services are as busy as ever.

Dr. Russ Cucina has been leading the preparations for this week for a couple of years. His budget, he tells me, is $116 million -- small change compared to the $2 billion Kaiser spent to convert to Epic -- yet a massive project nonetheless. Each implementation of Epic is so unique that it is given its own name -- Kaiser's is HealthConnect, UCSF's is APeX. For a nursing/medical informaticist, this week is history in the making, not to be missed. The project is a remarkable success and I have the good fortune to see it up close.

During this week, I am enrolled in UCSF's School of Nursing's Summer Academic Enrichment Program (SAEP), an upbeat introduction to its advanced practice and research offerings. For me, the best part is the clinical rotations, selected according to attendees' interest areas. Mine was not in a nursing unit but in the Nursing Ops area of the APeX go-live Command Center.

The Command Center has the staffing, technology, and aura of ground control for a moon shot. Perhaps a military metaphor is even more accurate, as it possesses a spectrum of clearly-defined job roles and responsibilities in a complex hierarchy with logistics, processes and procedures precisely scheduled. Dr. Cucina's team -- a hundred people or more -- is focused and professional.

In my rotations, I shadowed a couple of the Informatics Nurse Specialists (INS RNs) who performed a scout function, rounding from one hospital unit to the next, checking in with the local "super users" (nurses who had received special training in preparation for deployment of the new system) to detect and report software and process issues, and to confirm that fixes are "pushed out" and solve problems as promised.

My INSs were Craig Johnson, RN, and Sandy Ng, RN (pictured here with me). Brilliant and hard-working, they taught me a lot. Many thanks to you both, and congratulations to UCSF on achieving a major milestone!

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Silent organs

Jan. 2012 -- Having worked as a smoking cessation counselor, I can attest to the difficulty of achieving this particular behavior change. Those who work with alcoholics describe their work similarly. Both behaviors have dire health consequences yet are consummately difficult to extinguish. Part of the reason is that the organs that are damaged by these behaviors are "silent" -- without pain or sensation -- until they are in extremis.

If lungs felt pain when their delicate alveoli were damaged by toxic smoke, it would be easier to get people to stop. Finding the sensations unpleasant, they'd be less likely to continue. Assaulted by alcohol, the liver, too, suffers damage silently. Alas, evolution did not anticipate tobacco or alcohol and hence provided no detection of the harm they do. This silence facilitates the denial that perpetuates the harmful behaviors.

Compare this to, say, traumatic injury or heart attacks. These things hurt, so people avoid them. In my smoking cessation work, I would depict the processes occurring in lungs, circulatory system, and even the bladder when assaulted by the toxins from tobacco smoke, in an attempt to apply reason to decisions that are unreasonable. Alas, education is a less effective motivator than pain. Those silent organs make it a hard job.

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Lateral violence

Dec. 2011 -- In an article entitled No Tolerance for Bullying, the Advance Web for Nurses reports that the ten common behaviors of lateral violence in nurses, as described by Martha Griffin, PhD, RN, CS, director of nursing education and research at Boston Medical Center, Boston, are: non-verbal innuendo, verbal affront, undermining actions, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect privacy and broken confidences. Have you seen these in the workplace? Whom of us hasn't?

Lateral violence is getting increasing attention in the media. Another recent article at the www.nursetogether.com web site entitled, Ending Incivility in the Nursing Profession posits that lateral violence is often considered normal by nurses and describes it as an "oppressed group behavior".

As I have seen, it starts even before the workplace -- it starts in nursing school. I had several experiences of it there. Though I was careful about interpersonal politics, run-ins with the bizarre personalities of some people in positions of power proved unavoidable. For example, one of my teachers, a rather strange man who in his lectures delighted in showing to our class videos of himself dancing in a pink tutu and boasted about the low prices of prostitutes in Thailand, took a strong and personal dislike to me and on one occasion accosted me in the hallway and, unprovoked, threatened, "I could flunk you! I could get you kicked out!" When asked about it in a meeting with the director, he denied the hallway incident and accused me of "having an agenda" though what that agenda might have been he would not say. The director did nothing.

The problem lies not only with individuals but with institutions. Lateral violence had occurred, yet no action was taken. As in some hospitals, some nursing schools do nothing to curb it. They ignore it rather than deal with it. From the director's perspective, in a few months I would be gone whereas the teacher would likely be there for years so her easiest action was to overlook his transgressions. The lesson to me was to expect no integrity from nursing institutions. Shame on them.

Is it the culture of nursing or the culture of the school that creates the climate of impunity for these behaviors? Does it matter? Regardless of the source, an ethically-run institution should not tolerate such behaviors. I stuck it out, turned the other cheek, and collected my sheepskin. Had I known what to expect, I would have chosen a different school, though it's not clear that another would have handled such issues any better.

Lateral violence should be recognized and dealt with. Instead, in nursing we are taught from the beginning to put up with it and that it's even ok to perpetuate it, as such behavior seems not to have consequences. Shame on us.

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Healthcare and advertising

Practice Fusion conference, 11/11/11 -- With 1300 other healthcare workers, I sat in a convention hall in San Francisco and observed panelists debate the merits and issues of Practice Fusion and the electronic health record industry in which it appears to be thriving. PF is an advertising-funded, free-to-its-users, web-based electronic health record.

The company was founded in 2005 by Ryan Howard, a youthful and energetic entrepreneur with big and timely ideas. Five years ago I had coffee with him, having just discovered word of his startup not far from the more conventional electronic medical record company where I was working at the time. I was interested to learn about the direction he was taking and the technology he was fielding. The marriage of healthcare and the web was, I believed and still believe, made in heaven. Instead, what I experienced was a blizzard of tech-talk buzzwords -- disruptive technology, web-enabling, silo-liberating, blah blah -- nothing about medical data standards, medical office workflow redesign, new paradigms for medical data ownership, and so on -- the meat of the issues that such a system would surely challenge.

The tenor of the conference was much the same -- lots of fluff, a half hour of music by a gospel choir, feel-good cheerleading, not much content. Mr. Howard himself delivered one of the pep talks. In it, he claimed that PF's patient population was bigger than Kaiser and Sutter Health's (our two largest Northern California hospital chains) combined. While it may be true that portions of 22 million patients' medical charts do reside in PF, these patients are not PF customers, they are PF users' patients. Unlike Kaiser and Sutter, PF provides no medical care, nor does it employ thousands of doctors or possess thousands of hospital beds. The comparison is vacuous.

Regardless of flaws in PF's product, is the underlying business model -- and its potential effects on healthcare data management -- sound? Is a database attached to a web server the right place for my medical history? Is the Internet the best way for my caregivers to share and access it? What effect does this model have on costs and especially on outcomes?

The central feature of PF's business model is that it is funded by advertising, not by users. The doctors and clinics that entrust their patients' data to PF pay nothing for it. This surely has some effects on the nature and content of the service PF provides.

This raises several questions. First, is it a strategy for long-term survival? Every Internet user knows that before long, banners and advertisements "disappear". Our eyes learn to ignore them, and we rarely click them. There are even software solutions as popup preventers and flash suppressors to expunge ads from the screen. If the ads don't work, can PF survive?

If the business model is not viable over the long run, how will PF survive? As it is privately held, we cannot know for sure how it is faring financially, but my understanding is that today, after six years, it still runs not on revenue but on venture capital.

The deeper issue, in a medical decision-making setting, is whether advertising is ethical and appropriate. Does it skew treatment decisions? A heatedly-discussed precedent is the advertising of pharmaceuticals. The businesses that advertise make calculations about advertising in any medium, be it television, radio, newspapers, billboards, or the Internet. In any medium, the concern is return on investment. If advertising fails to increase sales, it will not be done for long. Thus, the mechanism must be that well-placed advertisements do indeed skew clinical decision-making toward the advertised products. Is this how we want our treatments chosen?

Any discussion of advertising must recognize the real product; what is being sold to whom. In this regard, the Internet is much like television. As is television to its audience, PF is "free" to its healthcare provider users. The payers are the companies that advertise. These are the real customers, and what is being sold to them is the attention of the users. So, in a sense, PF's product is not an electronic health record but the attention of its users, all those people in that convention hall.

Consequently, PF's product design and support decisions are driven less by the needs of patients, providers, and the exigencies of medical care, and more by what yields the biggest bang for the advertiser's buck. Does PF mine the data? For example, when a diagnosis of diabetes is entered, might an ad for a related product such as Metformin be displayed? I don't know and I bet PF isn't telling.

For strategies such as PF's, improvements in clinical outcomes and reductions in health care costs are at best a side effect. Is this how we want our health care data stored and managed? Despite my doubts about Mr. Howard and his company, I believe that the answer is yes. With HIPAA-compliant confidentiality safeguards, storage on Internet-connected servers enables wide access to patient data. It can spare us redundant tests, and eliminate the siloing of data in the file cabinets and computers of doctors' offices and hospitals.

Dearest to my heart (as is well known to readers of this blog) is technology's potential to put the patients themselves in control of their medical data. The trend is toward patient empowerment in medical decision-making. If PF moves this industry toward those goals, I applaud its efforts.

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UC
is
in
trouble

September, 2011 -- In the California budget crisis, most of the University's State funding has been cut. On a personal level, I am saddened and dismayed by our State's repudiation of its noble 1960 Master Plan for Higher Education. To it, I owe much of my own academic and professional career. In the bigger picture, to it our State owes much of its economic ascendancy to one of the world's largest economies, an achievement that is now threatened.

Our renouncing of this proud promise to our own future began in the '70s with Jarvis-Gann and accelerates today with mean-spirited anti-tax movements of Grover Norquist and his demagogic Tea Party offspring. The stepwise gutting of the mighty UC system is both tragic, putting top-flight University and graduate education beyond reach of ever-growing numbers, and short-sighted, reducing the growth of technology and culture, diminishing our prospects for a prosperous future.

This is a sad time indeed.

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Greedy nurses?

September 23, 2011 -- (to the San Francisco Chronicle)

Dear Editor --

I am a California nurse. Yesterday, 23,000 of us went on strike. Passers-by honked and waved and were almost universally sympathetic to our cause. If you are one of the few doubters, this letter is for you.

The nurses' unions are among the few that have not yet been eviscerated. Unions should be strengthened, especially in the light of the growing chasm between rich and poor, ballooning corporate profits, and what's been called the "Bush Economy." Without unions there would be no middle class. In the Bush Economy, profits and tax giveaways go to banks that do not lend and corporations that do not hire. Gut the unions and the fate of the middle class is sealed.

Yet some have called us "greedy nurses." There was even a full-page ad in yesterday's SF Chronicle claiming that nurses average salaries of $150K. In our dreams! No nurses I know earn six figures, and the one or two I've heard about do it by working overtime hours to exhaustion, a path to certain burnout.

The most important thing to know about nursing work is how hard it is, and how many, many years it takes to acquire that level of expertise and instinct that does, truly, save lives. For more than any other reason, patients go to hospitals for nursing care. Yes, they have procedures like surgeries and therapies, but part of why I prefer nursing to doctoring is that while the doctor gets ten minutes with the patient, the nurse gets an entire shift. That's where real healthcare happens. The personal, emotional, and professional commitment nurses put in to make this happen is unlike any other job. You can't imagine this until you've been there.

There is also a surprising amount of pure physical hardship. Here are a few quips from the culture of nursing:

  • What nurse hasn't dealt (many times) with a "code brown"?
  • And what do you call a nurse with a bad back? Unemployed.
Seriously, the number of workplace injuries -- especially needle-sticks in the age of AIDS, and back injuries from lifting today's epidemic of obese patients -- is shocking. This work is not just emotionally draining, it's dangerous. And you would begrudge nurses their vacation days and health care benefits?

So when I hear talk of "greedy nurses" -- especially from corporate executives like Sutter Health's CEO Pat Fry who awarded himself a $2M bonus this year -- my stomach turns.

The real challenge -- while applauding the nurses for holding their ground -- is to unionize the other professions and redirect some of this nation's wealth back down from the top. And if ever you get sick and then well again, thank a nurse!

Thanks for listening,
Dan Keller

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Hear
us
roar!

September 22, 2011 -- Today was the strike as planned. Only about 5% of the union nurses crossed the picket line. We are nurses, hear us roar!

California Nurses On Strike

Nurses at dozens of Calif. hospitals strike

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Strikes, yikes!

September 18, 2011 -- In three days (on the 22nd) thousands of Sutter Health nurses will go on strike and in sympathy with them will go thousands more Kaiser nurses. These are two of the largest hospital chains in Northern California. The nurses are defending hard-won employment contract terms (some health care benefits, some sick and parental leave benefits, etc.)

Especially pertinent in California, the only state with mandated nurse:patient staffing ratios (e.g. 1:5 in med-surg units) is participation in the staffing decisions, which, too, Sutter hopes to take away. This is important; it is one of the ways that nurses advocate for patients. Numerous studies have made clear the impact of staffing ratios on health care outcomes.

Of course, there are two sides to every story. The business of hospitals is a tough one (though Sutter is having record profits this year). Medicare reimbursements are being reduced, making it harder to "make the numbers". My friends in hospital management are stressed out (though not top management whose pay has seen handsome raises). Particularly problematic from the hospitals' point of view is the EMTALA Act that requires hospitals to provide care to anyone needing emergency treatment regardless of ability to pay. This means that the hospitals provide care for the medically indigent for free -- a tough way to run a business.

Nonetheless, I guess it's obvious where my sympathies lie. My CNA dues are paid up and I'll be out there on the picket line.

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Trimming the fat

September 15, 2011 -- Does Livermore have the most slender people?

Does nearby Los Banos have the fattest? Or does it have the most bariatric surgeons?

When you're selling a hammer, does everything look like a nail? Are high-tech healthcare choices driven by doctors who are also businessmen? (I have written on this topic previously.)

See the data for yourself at the California Healthcare Foundation's interactive map, released today.

The hardest question: what should we do about it?

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New fraud

September 1, 2011 -- Though retired now, my brilliant and inspiring grad school professor Dr. Donald W. Simborg continues to expound and illuminate. He writes with authority, having served as co-chair of the expert panel of a study group related to the Nationwide Health Information Network (NHIN) that looked at healthcare fraud.

He says, "Healthcare fraud is the most lucrative thing you can do if you're a crook... We're talking about a $250 billion problem."

In this month's J Am Med Inform Assoc (2011 Sep 1;18(5):675-7), he decries new techniques for fraud that have become enabled by modern electronic medical record (EMR) systems. These include:

  • Identity theft of provider IDs and patient IDs. This enables the fabrication of fraudulent claims.
  • Record cloning -- another way of producing fraudulent claims.
  • Copy forward -- data that is entered ahead of its actual collection, e.g. vital signs entered the day before the patient visit.
  • Single-click notes -- templated notes entered prior to the patient visit and subsequently left unaltered.
  • "Make me an author" -- an EMR feature that enables a physician to substitute their signature attribution for that of the person who actually entered a note.
  • Unaudited edits -- another "feature" that enables retroactive editing of a note without logging the amendment. Some vendors even enable the suspension of audit trail logging.
  • Evaluation and Management (E&M) code optimization -- Some EMRs suggest "upcoding" (changing the Current Procedural Terminology (CPT) service code from which billing is generated to a more expensive one) of E&M codes, and indeed with the increasing use of EMRs we have seen a rise in Medicare billings.

I applaud my professor's call for better industry oversight. EMRs can do much to improve quality, continuity, and research in healthcare. They must not also serve as tools for fraud.

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National Health IT Week

September 12, 2011 -- Today is the first day of the Sixth Annual National Health IT Week, September 12-16, 2011.

Information technology is essential to healthcare, a fact our technology-worshipping country has been paradoxically slow to recognize. To see why, as always, follow the money.

Our for-profit insurance company middlemen have a sole incentive: their bottom line. The long-term benefits of effective IT systems -- things like quality, continuity of care, population-wide and longitudinal data collection and analysis -- generate no profits. Hence, they aren't reimbursed. Hence, we don't have them.

Most US hospitals still lack comprehensive electronic medical record-keeping. Those that do have them cannot -- indeed prefer not to -- share their data. Well-intentioned (mostly governmentally-funded) efforts at Regional Health Information Organizations have gained little traction and in some cases shut down. So the primary objective of this Health IT Week is "...to educate industry and policy stakeholders on the value of health IT for the US healthcare system."

It's astonishing and disheartening that we still have such a long way to go.

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Doctors and nurses are not enough

July 19, 2011 -- Today I shook the hand of yet another spirited and passionate public servant, Fiona Ma, California Assemblymember from my University's San Francisco district. Her work spans many issues but for me the one of most interest is, of course, health care.

Ms Ma's cause celebre in this arena is advocacy for Hepatitis B -- education, screening, vaccination, treatment and San Francisco's Hep B Free program. This is yet another ground-breaking collaboration between government and health care providers. We do a lot of that here; we are leaders!

Health care services are not enough. Public advocacy is another essential component and people like Ms Ma make it happen.

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A good guy at the top

July 14, 2011 -- Today I shook the hand of another warrior for the people: Dave Jones, California's new Insurance Commissioner.

He describes himself as an activist. What he doesn't say in this article but did say in his speech today at the Public Policy Institute of California is that he is a whole-hearted supporter of California's Senate Bill SB810, our best hope for a single payer healthcare system. (I've written lots about it in this blog.)

Inaugurated in January of this year, Mr. Jones hit the ground running, doing what he can with the limited powers of his office to restrain the insurance companies. For example, he has enacted in California (modeled on the federal reforms) limitations on the "overhead" that insurers can incur, requiring them to spend $0.80 of every premium dollar on actual healthcare (hospitals, doctors, medical and ancillary services and providers.) To everyone but the employees and shareholders of Anthem Blue Cross, that's still 20% of pure waste but it's a step in the right direction.

Go Dave!

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You'll be safe here

July, 2011 -- Some nurses are miracle workers. With the Mom and the doctors all but resigned to getting the baby out by C-section, L&D RN Diane says, "Let me see what I can do." She talks to the baby (still inside the Mom) and lets it know that it's safe to come out. The three of them work together, developing a deep trust, and often this enables the baby to be born the natural way after all.

Is this miracle work? Or the product of decades of experience, and the non-quantifiable but undeniable successes that can be attained with intuition and spirituality?

Where are the randomized, double-blind, peer-reviewed, reproducible, gold-standard studies and clinical trials? Combining these two approaches -- science and intuition -- gives patients the best outcomes.

It's eye-opening to see it in real life.

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Google Health is dead

June 24, 2011 -- From an announcement on Google's official blog, we learn of the end of a wonderful experiment.

Google Health was a great idea -- empowering patients with control over their own data -- that we applauded.

Alas, the business model was weak; not enough users (and no insurance companies) saw enough value to get on board. Its primary virtue was the real life implementation of a Continuity of Care Record -- something that we sorely need. The value was there but it was subtle.

In a fascinating analysis, Missy Krasner observes that the challenge (that proved insurmountable) was the dominance by "tethered" health care records, those operated by health care providers (hospitals, doctors' offices, and tertiary and ancillary providers such as outpatient services and labs). The drawbacks of these data silos is that data is not shared among providers, hindering patient mobility. Providers don't want to lose business by enabling patients to go elsewhere.

Nonetheless, PHRs (personal health records) such as Google's must ultimately prevail. KevinMD agrees with me: Google gave up on electronic personal health records, but we shouldn't. This will happen only with guidance from regulators. Obama's health care reform does this... alas, too late for Google.

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Cancer cures?

June 2011 -- My friend Dick Karpinski writes about "known but unused cancer cures" at his Cure Cancer Now Home web site. Though I'm not qualified to comment on the specific cures he discusses, I do not doubt that the unprofitable ones get little attention. Thanks, Dick, for raising our awareness.

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Woo Hoo! We're Winning!

May 2011 -- Senator Leno's Single Payer Health Care Bill Passes Health Committee... California OneCare: Full Care, For All, For Less -- check it out!

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Record Profits for Health Insurers

May 16, 2011 -- Want to know how things really work? Follow the money! Insurers Take In Record Profits as U.S. Residents Spend Less on Care -- translation: in these times of economic stress, we're living with less yet continuing to enrich these parasites.

Some experts believe the companies are trying to raise premiums before stricter regulations are enacted under the federal health reform law, such as a requirement that companies cover individuals with pre-existing conditions.
Translation: they, too, can read the handwriting on the wall. Big change is coming -- a vast bureaucracy to be dismantled! -- and not a moment too soon.

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1945 Empire State Bldg hit by airplane
Foreshadowing things to come?

When a B-25 bomber crashed into the 79th floor of the Empire State Building at 9:49 a.m. on Saturday, July 28, 1945, killing 14 people, the injured were rushed to Bellevue's Emergency Room. A nursing student at Bellevue at that time, my mother writes:

As students we always said, "If ever I'm in an accident, take me to Bellevue ER." The ER staff had an amazing ability to respond to the very serious situations that walked in or came by ambulance and to the bizarre, too.

Bellevue had (don't know if it still does) a museum -- a glass cabinet -- of things removed from the bodies of patients who showed up in the Emergency Room. One was a fairly large steel nut removed from a guy who was working in a garage on the night shift. He had screwed it on to his penis which swelled with blood so he couldn't remove it. Fortunately, he wasn't circumcised, so the multi-talented ER doctors circumcised him and in the process were able to unscrew him.

There were no private rooms at Bellevue, but each ward had a room for a V.I.P. or someone with a highly contagious serious disease. The less fortunate patients were housed in the enormous wards with dozens of others. There was one who repeatedly got out of his bed and peed in the corner. When asked by an angry staffer, "Where do you think you are?" he got himself a psych consult by answering, "Grand Central Station!"

In retrospect, this doesn't seem like an unreasonable reply. It was an enormous ward with 60 to 80 patients. There were beds on both sides and down the middle. There were no call bells. To get a nurse's attention to get a bed pan (or to be on the schedule for when bed pans were passed out from a wheeled stretcher where they were lined up on top), a patient had to get out of bed and find her. Tough luck for the patients who were too sick to get up!

If a Catholic patient died and was not on the "On Serious" list (a code meaning that he or she would need last rites) New York City could be sued. Patients got scared when they were put "On Serious" as a precautionary measure but we did it anyway to protect ourselves. On the night shift -- even if it was our first time in that ward, and even if we were working it alone -- if an "On Serious" patient died, it was our fault. If the patient was not breathing we would lift their eyelid and shine a light to check for a reaction. Living patients were not happy to be so rudely awakened. Then we rushed to the head nurse's desk to check the patient's card to see if he or she was "On Serious" and above all to see whether the patient was Catholic. If they weren't Catholic, we could breathe a sigh of relief and simply fill out an accident report. The duty of the student was first and foremost to protect the City.

When the night nurse supervisor made rounds during our shift, everything better be in order. (Remember, this was WWII and there were few nurses available; most were in the war zones. Students' education was work-centered, not education-centered.) There was an intern who could be called to the floor if necessary, but he had been answering calls half the night and had conked out in his room. The students hesitated to call him unless the patient was really in trouble so we rarely did. No one thanked us for our heroics but we knew and so did our patients. That was an unforgettable time.

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Non-Profit in Name Only

May 1, 2011 -- In a letter today to the San Francisco Chronicle, I wrote:

Thank you for Stacy Finz's article in today's newspaper exposing abuses by for-profit professional schools.

These practices are not limited to the for-profit schools. They also take place in the nominally non-profit schools.

I am a recent graduate of Oakland's Samuel Merritt University's school of nursing, another that preys on people hungry for employment.

SMU is a cash cow for its parent company, the Sutter Health hospital chain. According to its alumni literature, last year it earned $10 million profit on revenue of $40 million, a 25% margin. It is non-profit in name only.

So where do profits go in non-profits? Much of that leftover cash is funneled into the pockets of exorbitantly-paid executive staff -- profit by another name.

And where does all that cash come from? We ABSN (Accelerated Bachelor of Science in Nursing) students pay $52,000 for a year of poor-quality instruction. For example, Diana Jennings, the instructor of the so-called Nursing Research class (included in the curriculum to satisfy the accreditation checklist; Jennings delivered only one lecture in the entire semester) brightly proclaims, "Everyone gets an A!"

In addition to the high tuition, fees such as $420/semester are charged as "Lab Fees" for a lab that is almost always locked, and poorly stocked. In the few hands-on practice sessions that are offered, we must share and re-use supplies like bandages because the school doesn't buy them in adequate quantities.

Thanks for helping to expose an exploitative industry.

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Calif. Health Professional Student Alliance
California Universal Health Care Act

April, 2011 -- California Senate Bill 810 -- It's back! And coming up for a Senate Health Committee hearing on May 4th. (Thanks again, Mr. Leno!)

Let's save money (yes, our state budget is deep in the red) and cover everybody at the same time. How? Eliminate the middle man! Let the State be the single payer. It works in Massachusetts. Why not here?

Though I'm no longer a student, I continue to support the goals of the California Health Professional Student Alliance (CaHPSA) and participate in its calls to action. I have telephoned my State Senators and let them know how important it is for California -- along with the national health care reform -- to move forward. Our "system" is a disgrace... but we can fix it. We must fix it. Go SB810!

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Judith Keller, RN
Beware the 3 Ds

April, 2011 -- "Beware the three Ds," my mother's nursing instructor intoned: "Drugs, drink, and doctors!"

It was 1944 and America was at war. The experienced staff nurses were abroad, serving in the U.S. Nurse Corps, providing medical care for the troops. Judith -- my mother -- had just graduated from high school and, newly-admitted to nursing school, was pressed into service to fill the need here at home. She writes:

In 1944, we were student nurses at Bellevue, a 3,000-bed hospital in New York City, on First Avenue. Described as a city within a city, its many buildings stretched from East 26th St. to East 30th along the East River. It had a prison, a mortuary, and even its own State Supreme Court.

Bellevue could not refuse anyone. If you were a patient in a private hospital and couldn't pay your bill, you were shipped off to Bellevue, no matter how sick you were. That was sometimes referred to as your "last ride".

It was a catchall for paupers, psychotics and criminals. Bowery bums loved to winter at Bellevue, finding some way to get admitted and, once admitted, would figure out how to make their thermometers spike a fever, assuring them of a warm bed for another night.

Bellevue was one of the world's great teaching centers. It was a coveted learning ground for young, new M.D. interns (the third D!) and for student nurses, too. With the seasoned nurses gone, the student nurses filled in, taking classes during the day and covering on the wards at night.

It was hard work. Students were assigned to medical and surgical wards, immense rooms with 60 to 80 patients, none of whom we had seen before. On a good night we had a nurse's aide, but often we were alone with all these very, very sick patients to care for.

At Bellevue, we treated the worst cases of the worst diseases. Nurses who had trained at Bellevue proudly wore their organdy caps with the ruffle all around and were respected wherever they worked.

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Hospice care improves quality of life when it's ending

April, 2011 -- Though it's already more than a year old, this article (from August, 2010), is such a valuable explanation of a vexing issue that I'm linking it here. One of my favorite writers on health care, Atul Gawande in the New Yorker, observes that modern medicine is good at staving off death with aggressive interventions — and bad at knowing when to focus, instead, on improving the days that terminal patients have left. A good read on an important topic.

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Cardiac resuscitation
Words!

March, 2011 -- As a programmer and nurse, I can tell you that "coding" means something awfully different to each!

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Gray Davis and Gavin Newsom at UCSF

February 24, 2011 -- At my alma mater UCSF, I attended a symposium on innovation in California. Innovation is our strength (Silicon Valley!) and it will create jobs and revive our economy.

The symposium was a star-studded event. The speakers included one of my heroes, Lieutenant Governor Gavin Newsom. Sitting next to me was Elizabeth Blackburn, a Nobel prize winner.

Another speaker was former California Governor Gray Davis (whose hand I shook). He said, "If you're born in the east, you grow up and you want to join something. If you're born in California, you grow up and you want to start something."

Indeed I do... Here it is (Powerpoint, of course)... Wish me luck...

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health care worker with handheld computer

February, 2011 -- The conventional wisdom says that government-run = low quality and inefficiency... But is that true? Not so fast, says Mike Doyle of Medsphere, a promoter of the Veterans' Administration's electronic health record system, VistA. I had an opportunity to learn and use VistA on one of my clinical rotations and found it excellent. Furthermore, the VA itself is a success story. In his well-researched blog, Mike writes:

By all rights, after all, the VA should offer the worst care anywhere: it's a gigantic, unionized bureaucracy, micromanaged by Congress and political appointees, and beset by an uncertain budget, an aging infrastructure, and a legacy of scandal. That it nonetheless outperforms the rest of the U.S. health-care system, on metrics ranging from patient satisfaction to cost-effectiveness and the use of evidence-based medicine, suggests that much of what we think we know about health care simply isn't true.
The VA is not the only example. Medicare proceeds with 3.9% administrative overhead (acccording to the New England Journal of Medicine's "Cost of Health Care Administration..."), compared to private insurer's 15-35% overhead, depending on whose numbers you use. For example, the Physicians for a National Health Reform's peer-reviewed studies say 31% of our health care dollar is spent not on medical care but on the overhead and profit of the private insurers (Anthem, Blue Shield, Aetna, Humana, etc.) And while it's true that the plural of anecdote is not data, my family's experience with Medicare has been excellent.

VistA works well and I found it easy to learn and use. Furthermore, the source code is in the public domain (open source) and stands a good chance of setting the standard for the industry. It makes electronic health record software affordable. Even Fox News has gotten behind it. Nonetheless, Doyle cites research that says:

Astonishingly, 20 years after the digital revolution, only 1.5 percent of hospitals today have integrated IT systems like the VA uses, and those that do often find their commercial software programs to be buggy and inadequate.
It's time for an end to the myth of quality and efficiency in private sector health care!

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kidneys

February, 2011 -- Occidental cultures generally hold that the human identity resides somewhere behind the eyes -- in the brain. For example, the Mind-Brain Identity Theory says that, "...mental states are identical with brain states." Not so fast, say I.

Damage to the brain is often associated with damaged thought processes. For example, Oliver Sacks "...throughout his career as a physician and neurologist, ...studied patients who exhibited 'a strange mixture of [mental] strengths and weaknesses.' His patients had autism, William's Syndrome, Tourette's Syndrome, amnesia and other conditions." When the brain malfunctions, thoughts malfunction. However, this does not preclude the involvement of other bodily organs in personal identity and thought.

Our Western notion that identity, thoughts, and feelings reside exclusively within our skulls is at best dubious, more likely erroneous. Ask anyone who has undergone an amputation. As nurses we are taught that phantom pain is real pain but more than that the amputee will tell you that part of themselves -- not merely an extremity -- is gone.

Carl Jung, 1912 Another way in which our sense of self encompasses more than the contents of our heads becomes clear with the deaths of family and friends. In a real and profound way, with each such passing we lose part of ourselves. We exist not just in the context of our bodies but also in terms of the people who know (or knew) us, our accomplishments, personalities, and personal histories. As our isolation increases, our place in the world is diminished. There are vocabularies for discussing this, for example Carl Jung's collective unconscious in which we exist not only individually but also in community.

Nearly every Latin love song refers to the coraçon -- the heart -- as the locus of emotion. Eastern religion and medicine recognize a dozen or so chakras -- pathways for flows of energies in the body -- located along the spine, in the ovaries or prostate, the throat, and so on. In our own western culture we speak of visceral emotions and gut feelings. Our skin crawls; we know things in our bones; and so on. The point is that all these organs participate in the formation of our consciousness and our emotional state.

My hypothesis here is that the kidneys are especially central to emotional state. In nursing school, we learn that they regulate fluid and electrolyte balances. These in turn drive cognition and mood. When the kidneys do not sufficiently remove ammonia from the bloodstream, we become demented. When they imperfectly regulate our bodies' acid-base balance, we become acidotic or alkalotic and thus agitated or lethargic. We think with our brains and with our kidneys.

The distinction between mind and body is a paradigm of our western culture, at times useful but at other times driving us to discussions of placebos (with which the mind bluffs the body), etc., that emerge as corollaries. We believe this dichotomy deeply. But what if it weren't entirely true? Another model might serve us better. What might it be called? The Thinking Body? Placebonics? Kidneys 'r us?

We do think with our brains... Also our hearts, guts, skin, bones, kidneys -- the mind is the whole body! What a concept!

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Dan with nurse's cap

February, 2011 -- California RN license #790869. At last.

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two separate funds for two separate purposes

February, 2011 -- Healthcare dollars are spent in two fundamentally different ways and should be collected and managed accordingly. These are:

  1. Preventive and predictable health care expenses: our children's immunizations, prenatal care, our routine diagnostics (PSA tests for older men, mammograms for older women, etc.), and our periodic checkups. These things are completely predictable from the moment we're born -- indeed, from the moment we're conceived -- through our entire lives. The costs should be budgeted and funded for every one of us without exception. We should all pay into a system that provides them, and there is no reason for anyone to earn a profit from it. It's a public service like law enforcement and fire departments and should be funded and provided similarly, by publicly-funded, local community clinics. There is no place in the preventive/routine care part of a rational health care system for for-profit insurers. The incentives in such a system are wrong and result in a system that's unfair and that delivers inadequate care.
  2. Costs of casualties and illnesses (unpredictable): should be managed as insurance in which risk is shared across an entire population. The services are best delivered (as they are today) by for-profit, centralized, high-capital-cost, acute-care facilities (hospitals and specialized service units such as dialysis centers, imaging centers, clinical labs, psychiatric offices, and hospices). Anyone to whom a casualty or illness happens would be covered, and everyone would pay in to the fund equally (the "triple mandate"). The fund would reimburse the service providers with preference and incentives for those that provide the best care and the lowest prices.

This is just common sense. None of this would prevent anyone from buying any other health care service, or from using the provider of their choice who might be "outside the network". Anyone can buy whatever they want if they have the money. The Canadians have forbidden this, saying that it would create a two-tier system and perhaps they're right. Alas, we already have a two-tier system in the USA, and it's ugly: those with and those without. Obama has taken some baby steps toward an overhaul... A good start. We need that and a whole lot more!

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health care and money...

January, 2011 -- ...And pound-foolish. Health insurance (mine is Blue Cross) will not pay for medicines if they are over-the-counter. They pay only for prescription medications, those that are ...licensed medicine that is regulated by legislation to require a prescription before it can be obtained. The term is used to distinguish it from over-the-counter drugs which can be obtained without a prescription. For example, my eye doctor prescribed Ocuvite, shown by controlled, randomized studies to delay onset of age-related macular degeneration. My Dad had that; if I live as long as he did, I will probably get it, too. There are some treatments (not cheap) but of course it would be better to delay or not to get the disease at all. But Blue Cross won't pay for Ocuvite because it's not a prescription drug.

Why is that foolish? Because health insurers save a nickel today and spend ten dollars later; their business model requires that they be stingy regarding prevention but generous regarding cure. I also saw this when I worked as a tobacco cessation counselor. My patients could not get reimbursed for the few hundreds of dollars cessation classes cost, but when they cost tens of thousands later for their lung and other cancers, heart disease, and COPD... no problem!

Why is it so? These short-sighted policies are demanded by how corporations work: they must show continually-rising short-term profits. This is done by minimizing expenditures in the present quarter. Higher costs in the future? They'll deal with that when the time comes. This is the behavior that's good for Wall Street, but it's bad for our health. The incentives are wrong. This is why -- by definition -- for-profit companies should not be in the business of making health care decisions. What would be a suitable alternative? Single-payer, of course!

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SMU 2010 San Mateo ABSN cohort
Pinned!

December 19, 2010 -- Today was nursing school pinning (that's what nurses call graduation.) Now I have the "N" in "RN"... To get the "R", I will soon take the NCLEX, the State Board exam that gets me my license to actually do nursing work.

What's remarkable is how little we new grad nurses know about how to do the work nurses do... Especially given the $52K/yr we've spent to get here. Hospitals are reluctant to hire us because we are nearly useless. Hiring us is a big commitment because hospitals must make such a big investment in us (lots of mentoring and initially low productivity) to get us up to speed.

It doesn't need to be this way; nursing education could be effective. My school was mediocre but (and I have evidence for this) they all are. But that's a topic for a different discussion... For now, I am just celebrating. Video. Hurray for pinning!

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men at work
Men at work

December 12, 2010 -- In one week I will graduate from nursing school. At long last! The ceremony is called "pinning" and is a throwback to the old days when nurses wore little white hats and making tight hospital corners mattered more than patient care.

I am a new nurse, entering this as a second (well, third, but who's counting?) profession. I bring the perspective of experience in other work realms, and I have less tolerance for mediocrity than my fellow nursing school students who are half my age. More to the point, I have little tolerance for mediocrity in my nursing school faculty whom, to their chagrin, I perceive as peers (indeed, most are younger than me.)

Evidently there are many like me: older men entering nursing as a second profession. "Nearly 40 percent of students studying to become registered nurses are over age 30... candidates who already have four-year degrees," [from the New York Times, Nov. 7, 2010: 45, Male and Now a Nurse]. I'm not 45 but 56, and have both a four-year degree and a Master's, but the idea is the same. My nursing class exactly matches that in the NYT article: 15% male. What the article doesn't mention is the darker side of this trend: education to produce degrees like mine (the school sells BSNs) is now a big business. My school (which I'd better leave nameless for now, since I'm still in its clutches) is -- let's be magnanimous here -- lackluster in the quality of its teaching though expensive ($52,000/year not including books and supplies) and very profitable ($10M profit on $40M gross revenue).

Fortunately, the quality of the education is largely irrelevant to the quality of the nurses entering the profession. Most of what we new nurses need we will learn on the job, not in the classroom. In other words, we emerge from this expensive and unnecessarily fractious process knowing almost nothing of what we'll need to know to be good at our work. New nurses need lots of nurture from the institutions that accept them before they become useful.

This raises several important questions: how can nursing education be made effective? How can new nurses ("nurses eat their young") come up to speed without getting beaten up along the way?

Why does this matter? Because we want good health care. Given that the 3.2 million RNs now in practice form the vast majority of the health care work force, we need them to be good at their jobs and to get there quickly. The present dysfunctional system of producing new nurses is ripe for an overhaul. That will be good for us all.

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dear diary...
Dear diary (excerpts from my clinical journal)

In nursing school, the most valuable part of the process we undergo is the clinical rotations.

The clinicals are where the rubber meets the road. Here, we work with live patients in local hospitals. Each semester, we are assigned to a different type of nursing unit so that by the end of the program we have had a taste of med-surg (the most important), peds, SNF, ICU, oncology, emergency, psych, telemetry, a community clinic, and perhaps others. These are fascinating, difficult, and stressful. Some of us kept journals. I did. Here are my writings.

Feb. 18, 2010, Kaiser, med-surg, Santa Clara: At the same time exhilarating and challenging is the access granted by nursing work. In ordinary human interactions, there isn't permission to poke and pry... More

Feb. 23, 2010, Kaiser, med-surg, Santa Clara: Infection transmission precautions are driving me nuts. Those bacteria have us whipped... More

March 3, 2010, Kaiser, med-surg, Santa Clara: I remember distinctly a comment made by one of my clinical instructors from the first time I went to nursing school about four years ago. She observed that I was having difficulty finding my "rhythm"... More

March 17, 2010, Kaiser, med-surg, Santa Clara: Nursing education is focused on the hospital setting with its enormous resources and fine-tuned protocols. What about nursing in other environments? ... More

July 8, 2010, O'Conner Hospital, monitored (telemetry) med-surg unit, San Jose: Listening is a challenge. I could not hear 9121's heart!... More

July 17, 2010, O'Conner Hospital, monitored (telemetry) med-surg unit, San Jose: Still have occasional moments of, "OMG what (of the hunded possible tasks) should I do next?" but they last only five seconds... More

Aug. 23, 2010, Veteran's Administration Hospitals, Palo Alto and Menlo Park: After all the flack in the press about the sorry state of affairs at Walter Reed hospital and the right-wing excoriations of our government's purported neglect of our brave men and women formerly in uniform (i.e. veterans) it was eye-opening to see how well, in fact, they are cared for... More

Aug. 30, 2010, Veteran's Administration Hospital, Menlo Park: I'll be blunt: the time doesn't feel very productive... More

Sept. 13, 2010, Veteran's Administration Hospital, Menlo Park: A couple of brief but illuminating patient interactions have given me pause. In the first, Mr. F., one of the more belligerent and combative patients... More

Sept. 29, 2010, Veteran's Administration Hospital, Menlo Park: On a personal note, at the risk of appearing unprofessional, I'd like to add that I felt at least a twinge of disappointment at my inability to "connect" with this patient... More

Nov. 25, 2010, Emergency Dep't, Kaiser, South San Francisco: Nursing is, of course, about people. As a student on this rotation I had the luxury of being able to take time to listen... More

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brain
Brainy nurses

December, 2010 -- Nurses carry information in their heads -- a lot of it! How do they remember everything they need to remember? They use their brains!

This sounds silly but what nurses mean by the term "brain" is the piece of paper they carry in their pocket on which they keep track of the zillion patient and task details their job demands. (Sharon McLane, MS, MBA, RN-BC, and now PhD of the University of Texas at Houston documented this in her 2009 PhD dissertation, Understanding Nurse Created Cognitive Artifacts. "Cognitive artifact" is a fancy term for that piece of paper.)

I collect brains and you can see my collection in my brain museum. Each brain is in its own way clever and meets its nurse-creator's memory needs. Fascinating... and brainy!

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ambulance
Emergency!

December, 2010 -- This month I am completing my clinical rotations with a stint in the emergency room of a major local hospital. I have seen some awfully sick people walk in that automatic door or, worse, roll in on gurneys and wheelchairs. It is sobering to see suffering, and gratifying to occasionally be able to do something about it. Health care is like no other work in the world!

My friend and fellow UCSF alumnus Mark Wandro blogs about his lengthy and impressive experience as an emergency nurse. Also fascinating is the Emergency Nurses Association web site. Good reading -- give them both a visit!

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State Senator Mark Leno
Public option, public sector

November 19, 2010 -- Today I shook the hand of another of my heroes, California State Senator Mark Leno. He is a man of principle! Part of my University (UCSF, where he spoke) is in his district.

Contrary to the loathsome and self-serving declarations of such right-wing demagogues as Grover ("shrink government to the size we can drown in a bathtub") Norquist, the public sector, says Mr. Leno, is critically important. Not only because it is the best mechanism for delivering such services as public safety and justice, but because without it there can be no revival of the private sector. It creates the foundation upon which growth can occur. Around the world, the countries where growth is limited are those with little infrastructure. And (dear to our UC hearts) public education is a big part of any robust infrastructure. An educated middle class has been an essential part of what has made California the world's eighth economy.

Mr. Leno has been instrumental in the revival of Sheila Kuehl's Senate Bill 840 (which, placating his monied friends, Governator Schwarzenegger twice vetoed) as SB 810. Don't be fooled by the misinformation, Mr. Leno tells us -- no one is asking for "socialized medicine". Rather, what we need is health care that continues to be privately provided but publicly funded. Eliminate those middlemen, the health insurance companies, whose profit was $12B last year yet added no value. Like me and a lot of people, he is convinced of the need for a single payer. This is the only way to contain costs.

With Jerry Brown in the Governor's seat, Mr. Leno will reintroduce this bill. Will Mr. Brown sign it? When he campaigned with Bill Clinton, Mr. Brown was a knowledgeable advocate for a single payer system. As Governor he will no doubt feel pressure from the right and how he will respond is anyone's guess.

Expect, said Mr. Leno, a huge disinformation campaign from the insurance companies. We must innoculate the public with education about single payer -- "Medicare for all" -- an idea whose time has come and yet another opportunity for California to lead the nation.

Guided by visionaries like Mark Leno, we have hope once again.

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angel with world
Change the world

October, 2010 -- Calling all angels! Well, not all angels, just the right angel... an angel with vision, insight into the challenges of health care, and that burning fervor to change the world. Well, not the whole world but an important part (nursing) of an important part (health care) of the world.

What needs to change about nursing? It's a hard job (no surprise) with lots of details to keep track of (ditto) and a zillion tasks nurses must remember to do (ditto ditto) yet they get no help (whoops!) No one teaches (or has even thought much about) how nurses can/should do time management and no one has provided tools to help with this... until now!

What do angels have to do with it? Our development time and marketing efforts could benefit from angel funding. Are you the angel we seek? Get in touch... Let's do well while we do good. Join the team and together let's change the world!

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Dr. Atul Gawande
Want a hero?
Or a checklist?

October, 2010 -- What do you want from your doctor, heroism or checklists? Say you're going in for surgery. Do you want your surgeon to exhibit "expert audacity"? Here's how Atul Gawande describes it in The New Yorker, Dec. 10, 2007, in The Checklist:

We have the means to make some of the most complex and dangerous work we do -- in surgery, emergency care, and I.C.U. medicine -- more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity... Checklists and standard operating procedures feel like exactly the opposite, and that's what rankles many people.

Or would you prefer that your surgeon follow a checklist as did the pilot Sullenberger who brought down his failing passenger jet in the Hudson River without losing a single passenger? He said he was no hero but was well-trained and following the procedures.

We Americans love to say of our advanced medical care that we had the best doctor... That our doctor is a genius... That a good outcome is thanks to that skill, that extraordinary person... But this is not a model that scales well nor is it conducive to widespread good outcomes. Only a few people get to be worked on by that genius. And if evidence-based medicine is truly at work, then the "genius" is simply following the best evidence, which every well-trained practitioner should do. (Here is Gawande in 1/29/2009 NEJM, A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.)

Dr. Gawande says that medicine should be more like aviation -- no pilot would fly without first running through his pre-flight checklist, and then using yet another checklist for each situation and task that arises. Checklists are so valuable that he has even made a checklist of steps for making checklists. Of Sullenberger he says:

...it wasn't flight ability, but instead adherence to discipline, and teamwork... Because there were checklists, and because everybody used them... The heroic part of that flight was not the flight ability of Capt. Sullenberger, it was the willingness of the entire team including the flight attendants, who... acted through their protocols.
For my doctor I don't want a hero. It's time to end the culture of expert audacity. I want a well-trained expert, equipped with the best evidence... and the best checklists!

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Nursing and Environmental Health
Environursing

October, 2010 -- Environmentalism and nursing? What's the connection? Turns out it's a strong one, and we learned about it at the Children First: Promoting Ecological Health for the Whole Child conference at UCSF this month.

The intersection of environmentalism and nursing includes:

...nutrition, education, socio-economic status, exposures to toxic chemicals, and access to preventive health care.
If you're a nurse -- you care for people -- how can you not be an environmentalist? Join us at www.enviRN.org.

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Nurse Ratched -- the most famous psych nurse
Don't call it compliance

September, 2010 -- As nurses, how do we perceive the work we do?

This semester, my clinical rotation is in mental health ("psych") nursing. One of the terms of art is patient compliance -- are they taking all their pills? But we don't call it that any more. Now the preferred term is, in the spirit of patient empowerment, adherence. In other words, we prefer to think they take their pills by choice. In her heart of hearts, though, the psych nurse will admit misgivings about mental health care being little more than polypharmacy.

Oh yes, and we don't call them patients anymore, either. Now they're clients. Perception is everything.

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obesity and fast food billboards
Shoppin' spree?

August, 2010 -- The irony in this pair of billboards speaks for itself. Thank you, Friends of Irony.

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medical record trapped
Double mandate? Make it triple!

August, 2010 -- When we were arguing about health care reform, much was made of the proposed double mandate. This is the idea that the obligation is on both sides -- insurance companies could no longer turn anyone away, and every health care consumer (you and me) is obliged to buy in. For example, the Huffington Post says, in A Double Mandate for Health Works for Europe: "Most European countries mandate that every citizen must buy insurance coverage. They also mandate that every local insurance company who wants to do business in the country must sell coverage to any citizen who applies for that coverage. Health screens are not allowed."

This is eminently fair and reasonable. The system works best when everyone participates. But I propose we take it one more step.

I propose an even higher degree of fairness -- a triple mandate: everyone must be covered, everyone must participate, and everyone should pay the same. Being young and healthy should not entitle you to a special price. Most people are or were once young and healthy. If you're sick you shouldn't have to pay more. Sooner or later most of us get sick, at least somewhat.

Sure, some people won't be able to afford it. So subsidize them with a government program. We already have government programs to help people who cannot afford health care; the cost of these programs would stay the same or perhaps even decrease due to the larger coverage pool. But this is a detail.

Here's the point: We are a nation of realists; I help my neighbor knowing that someday I may need the favor returned. I do not deserve punishment for my health misfortunes and neither do you. Sharing the risk makes us all stronger. Sharing it equally is fairest. And a system that is truly fair would be something for us all to be proud of. Push for a triple mandate!

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medical record trapped
Control your own medical data? Try it!

May, 2010 -- I am one of those "empowered" patients. I labor under the illusion that I retain some control of my medical data.

Try it yourself -- run this little experiment:

  1. Next time you get an order from your doctor for a routine lab test, have him or her write the following instruction on the order: "Send results directly and only to patient."
  2. Make sure your mailing address and fax number are included.
  3. Then find a lab that will perform as ordered. Good luck!

Here in San Francisco I went to three different retail clinical labs before I found one that was willing. And even so it took some arm-twisting and remonstrating to convince them that yes, they should do exactly as the order said... no, they should not send the results to the doctor... yes, they should send them (only) to me... yes, it's legal... yes, my insurance (Blue Cross) would reimburse as usual... no, it's not a violation of anything, and... it shouldn't even be unusual. Yet it is.

Get with it, people! Take possession of your own data! Insist on it! Of course you should share it with your doctor. But it should be yours to share, in your control. Our being empowered patients shouldn't be unusual. It's time for the labs (and everyone else) to get used to us!

Postscript (two weeks later): Surprise. The lab completely ignored the instructions and sent the test results to the MD. I have filed a HIPAA violation complaint. Here are the instructions and forms on the web site of the U.S. Department of Health & Human Services in case you, too, need to do this. Stay tuned... I'll record any progress right here on this page.

 
Post-postscript (two months later): The Dep't of Health and Human Services replied to my complaint. They pointed out that the law says that clinical lab test results must be provided only to the licensed health care provider who ordered them. So the lab, in defying my instructions was "right"... it's the law that's wrong! Not only does the patient not own the data, he/she doesn't even have the right to see it unless the MD assents. Disempowerment gets no worse than that. Broken laws? Let's fix them!

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ThinkLabs stetho headLittmann stetho head
Conformity and stethoscopes

May, 2010 -- Who is reluctant to try something new? It's not whom you'd think. Is it the oldsters, set in their ways? Guess again!

I recently called ThinkLabs with a technical question about my new digital stethoscope. The phone was answered by Clive Smith, the inventor of the device and CEO of the company.

We proceeded to have an animated discussion about his product and its users. They're not whom you might have guessed: younger, more experimentative healthcare practitioners. On the contrary, said Mr. Smith, it's the older ones who are willing to try something new.

Stethoscopes are a powerful cultural icon. Wearing one around your neck is a kind of badge of honor. Its appearance is determined more by tradition than by function. Like Leo Fender's cutaway electric guitar body from whose shape few have dared deviate in 50 years, stethoscopes must appear just so.

I can confirm Mr. Smith's statement. My nursing school classmates all wear Littmanns. They wouldn't dare try something slightly non-conformist even if it worked much, much better. Indeed, none of my classmates have even asked to try mine. Yet the ThinkLabs is much, much better.

Imagine this: a volume control! You have an obese patient and you can hardly hear anything through that flesh? Turn it up! What a concept!

By the way, Nurse Jackie wears a ThinkLabs.

This sounds like a commercial but really what I'm describing is the freedom of being an old-timer. The youngsters don't feel free to experiment. They are afraid to look different. Mr. Smith faces a challenging obstacle.

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nurse using computer
Do nurses compute?

April, 2010 -- The California Healthcare Foundation reports in its Survey: Nurses Divided on Whether EHRs Have Improved Patient Care that half of nurses say that electronic health records have had "a positive effect on the overall quality of care."

And then there's the other half. My own experience -- now that I've worked with yet another EHR (Kaiser's HealthConnect by Epic) on a few clinical rotations -- is that nurses do spend an awful lot of time in front of the computer. This could easily lead to the perception that it takes away from time with patients. But is that true? Didn't they also spend a lot of time charting on paper before there were electronic charts? And isn't it also true that record-keeping and access is far better than it ever used to be? Especially with bar code readers and the electronic Medications Administration Record (MAR) the chances for errors are substantially reduced. So in this writer's humble opinion, computerization has helped make nursing care a lot better. Or at least half of it.

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addiction
Addiction phobia

April, 2010 -- Working my clinical rotations this semester I saw first-hand in the suffering of a patient our medical system's dysfunctional approach to pain management. This young man suffers from a gastrointestinal condition that is painful and cannot be cured. Yet his doctors will not give him ongoing opiate analgesics, the only thing that enables him to get through a day relatively pain-free. They do prescribe these drugs for his acute episodes but then they send him home with non-opiates that, he says, "...do not touch the pain."

Evidently, the concern is that he might become addicted. But I wonder, so what? He has the disease for life, why not the treatment for it, too, for life? I cannot second-guess the doctors but I can commiserate with his frustration.

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Paul Krugman
Krugman nails it again

March, 2010 -- In another New York Times op ed entitled Health Reform Myths, Nobel prize-winning economist Paul Krugman points out three myths that bedevil proponents of health care finance reform. Lots of people believe:

  • President Obama is proposing a government takeover of one-sixth of the economy, the share of G.D.P. currently spent on health.
  • The proposed reform does nothing to control costs.
  • Health reform is fiscally irresponsible.

Go read the article if you've fallen for any of these.

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Recognizing diabetes

March, 2010 -- We fledgling nurses spend a lot of our time dealing with diabetes. It's grown to be an epidemic. I'm studying for an exam. There will be questions about how to recognize it in our patients. When you read the symptoms of a disease, sometimes it seems like every disease has every symptom. But anyway, here goes...

HypoglycemiaHyperglycemia
Fasting
Blood
Glucose
<60>100
Onsetrapidgradual
Skincool, pale, diaphoreticwarm, dry, flushed
Mental statusdisoriented, comatoseawake, lethargic
Dispositionshaky, dizzy, agitatedhungry, blurred vision
Respirationnormaldeep, rapid, fruity odor
Pulsenormal or fastfast, weak
BPnormal or highnormal or low
Seizurecommonuncommon
Urine polyuria
Thirst polydypsia
TreatmentPO or IV glucoseSQ or IV insulin, K+
Recoveryrapid (minutes)gradual (days)

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A new stethoscope... and a sermon

March, 2010 -- I have decided to buy a fancy new stethoscope, one of the digital ones with ambient noise rejection and other cool stuff... hurray! Maybe now those elusive murmurs will be a little less elusive.

Clive Smith, the CEO of the company (Thinklabs) that manufactures it has a spirited blog. He writes:

...let me make a prediction on healthcare reform. A bill will be passed, one way or another. Due to the special interests that have written this bill and influenced both parties, no "cost cutting measures" will be truly effective. Congress will mandate coverage of pre-existing conditions and many more people will have insurance coverage, which is a good thing. However, with no real cost cutting, insurance companies will skyrocket premiums, arguing that Congress forced them to provide all that new coverage. That the insurance companies wrote the laws will be forgotten.

Opponents of reform will argue that it was an abject failure due to skyrocketing costs. That these opponents of reform prevented cost-cutting measures to pass will be forgotten.

The people will complain that they wanted healthcare reform and cost cutting and instead, they got increased premiums and healthcare costs even more. That they, too, were supposedly opposed to healthcare reform and wanted no government intervention to contain costs will, too, be forgotten.

What will not be forgotten, by those who have tried to promote true healthcare reform, will be that they were painted as the enemy, they were maligned, and they were blamed for the outcome when the mob, influenced by special interests, attacked them for their efforts. What will not be forgotten is that trying to reform healthcare is a losing political position and it's not worth risking one's neck... the politicization of this discussion, the hysteria, the lobbying money, and the abject ignorance of The People... resulted in the destruction of all rational thinking and analysis. We will all be the worse off for that sad outcome.

I like this guy. And I'm buying his product. Health care financing may be a mess but at least I'll be hearing my patients' insides better.

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Blame the Lawyers

Feb., 2010 -- My friends on the Right love to blame the lawyers. Who doesn't?

In an Oct. 1, 2009 article in the Los Angeles Times entitled Tort reform is the healthcare debate's frivolous sideshow, Michael Hiltzik writes:

You know the argument: Disgruntled patients, goaded on by unscrupulous lawyers, file frivolous malpractice lawsuits and walk off with millions of dollars in undeserved awards granted by teary-eyed jurors. Doctors respond by practicing "defensive medicine," ordering lots of unnecessary tests to cover their behinds. Bingo! Medical costs hit the stratosphere.
But then he goes on to dispel this myth.
The truth is that medical liability isn't a big driver of health costs... the cost of malpractice litigation, in court and through defensive medicine, [is] roughly 2% to 3% of all U.S. healthcare spending.
So the tort reform "talking point" is indeed a "frivolous sideshow." Instead, let's focus on where we can make real change.

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Turkeys voting for Christmas

Jan., 2010 -- (Cross-cultural note for us Americans: in the UK, the traditional Christmas dinner is turkey.) A fascinating article by BBC contributor David Runciman entitled Why do people often vote against their own interests? reviews writings by Drew Westen and Thomas Frank about the psychology of many American voters:

...it is striking that the people who most dislike the whole idea of healthcare reform - the ones who think it is socialist, godless, a step on the road to a police state - are often the ones it seems designed to help.

In Texas, where barely two-thirds of the population have full health insurance and over a fifth of all children have no cover at all, opposition to the legislation is currently running at 87%.

...Why are so many American voters enraged by attempts to change a horribly inefficient system that leaves them with premiums they often cannot afford?

Why are they manning the barricades to defend insurance companies that routinely deny claims and cancel policies?

The answer does not increase my respect for the decision-making processes of American voters. Westen's explanation is paraphrased:
...stories always trump statistics, which means the politician with the best stories is going to win: "One of the fallacies that politicians often have on the Left is that things are obvious, when they are not obvious.

"Obama's administration made a tremendous mistake by not immediately branding the economic collapse that we had just had as the Republicans' Depression, caused by the Bush administration's ideology of unregulated greed. The result is that now people blame him."

Paraphrasing Frank, the article observes:

...voters' preference for emotional engagement over reasonable argument has allowed the Republican Party to blind them to their own real interests.

The Republicans have learnt how to stoke up resentment against the patronising liberal elite, all those do-gooders who assume they know what poor people ought to be thinking.

Right-wing politics has become a vehicle for channelling this popular anger against intellectual snobs. The result is that many of America's poorest citizens have a deep emotional attachment to a party that serves the interests of its richest.

The article is part of a series entitled Turkeys voting for Christmas... How apt.

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The Incentive that Works

Dec., 2009 -- The benefits of prescribing electronically ("e-prescribing") are numerous:
  • Fewer errors
  • Fewer avoidable adverse drug events
  • Decision support
  • Detection of drug-drug interactions
  • Improved record-keeping
  • Faster communication with pharmacies
  • And so on...
Indeed, e-prescribing is low-hanging fruit; many MDs have adopted this practice and prescribe this way... But not for the above reasons.

The true incentive? Money, of course. The Centers for Medicare and Medicaid Services (CMS) has implemented a program named MIPPA (Medicare Improvements for Patients and Providers Act of 2008) giving eligible e-prescribers an incentive payment of 2% of their Medicare Part B charges in 2009 and 2010.

All that quality-of-care stuff? Do-no-harm stuff? Nah! It's the green stuff that gets it done!

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Doctors? Businessmen? Or Both?

Nov., 2009 -- Reform of how we pay for healthcare is the hot topic of the day. I myself have expounded on this with excoriations of the health insurance industry. Blue Shield, Anthem, Aetna, Humana and their ilk are now everybody's favorite whipping boys and it's not undeserved. The relationship of these companies with their customers is by definition adversarial. They do their job "best" (in terms of profit-making) when they succeed in denying health care. But there is another, less obvious villain driving our costs up and our outcomes down: doctors who are also businessmen.

I am not the first to recognize doctors' conflict of interest. It has been documented in widely-circulated articles such as NPR's October 8, 2009 story, "The Telltale Wombs of Lewiston, Maine". Another article on the same theme in June's New Yorker has also gotten a lot of attention. Named The Cost Conundrum, it observes that when MDs are businessmen, health care gets expensive.

Indeed, there is an entire science devoted to the analysis of patterns of consumption of medical care and their effectiveness in terms of cost and and outcomes. It's termed utilization review and is naturally a topic of great interest to health care payers. Why has it failed to bring to light these maldistributions of service? Why is this issue not part of today's debate?

The NPR story describes how "...in Lewiston, 70 percent of its women would have a hysterectomy by age 70." The reason is not an unusually high rate of uterine disease; a now-famous longitudinal study revealed that numerous communities around the country have anomalous rates of certain medical procedures. The study showed "...how bizarre the distribution of care was. People in one town would get their hemorrhoids removed five times more often than people in another town only 30 miles away. Ditto with mastectomies, prostate operations, back surgery." How are these anomalies explained?

It is doctors, not patients, who drive consumption of medical services. Doctors who are paid for each service they render ("fee-for-service") tend to recommend those services to their patients. In other words, money. This is not to say that doctors are intentionally exploiting their patients but it is clear that their objectivity and judgement is colored by their own financial interest. "The U.S. health care payment system rewards doctors for taking action and doing procedures. This reality is so powerful that it hasn't just changed the individual behavior of doctors... the specialties themselves have changed, bending like flowers to the sun, moving toward the source of heat."

How should we solve this problem? Neither article goes so far as to propose a solution but I will. I propose that our healthcare payment reform legislation include language to do away with medical fee-for-service. A primary care doctor who also offers (and orders) ancillary services or tertiary care has, by definition, a conflict of interest. Why is this a revelation? Why hasn't it always been prohibited? What should we do about it? Here's what: put all doctors on salary instead. They should be paid the same no matter how many (or how few) hysterectomies they perform.

Of course this is politically impossible. The AMA and others would rebel and not mildly. But I have seen other countries (e.g. Italy where I just came back from living for a year and was most impressed by the quality and equity of the healthcare system) where it works just fine.

For me personally, this conundrum has an additional dimension. Among my closest friends are several doctors. Some of them are quite entrepreneurial and thriving. They work hard and well, and their ethics are impeccable. They would not appreciate the sentiments I express here. In conclusion, it can be said only that the healthcare debate is convoluted indeed.

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Gullibles, Libertarians, Partisans, Shills

Sept. 3, 2009 -- In a letter today to the San Francisco Chronicle, I wrote:

Dear Editor,

In raucous town halls around the country, opponents to proposed health care reforms seem mostly to fall into four categories that I label as follows:

  • The Gullibles -- listeners to right-wing talk radio screeds and outright fabrications such as Palin's death panels

  • The Libertarians -- those who oppose government in any form or role and view its actions (except perhaps military and law enforcement) as intrusion and theft-by-taxation

  • The Shills -- militant loudmouths delivered by buses paid for by Big Pharma and Big Insurance

  • The Partisans -- those who hope to see Obama fail at any cost (to these people, expense, outcomes, and quality of life are irrelevant... all that matters is Republicans "winning")

Every opinion deserves to be heard but now let's recognize the uninformed ones for what they are, move on, and get the job done!

Thanks for listening,
Dan Keller

PS -- They didn't publish it. Maybe next time.

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Jackie Speier Gets It!

Sept. 1, 2009 -- This evening, at a UCSF event to welcome our new Chancellor, we were privileged to hear a brief talk by Congresswoman Jackie Speier. Her congressional district includes UCSF (where I am Pres. of the Graduate Division Alumni Association).

She welcomed Chancellor-elect Susan Desmond-Hellmann and talked about the hot-button issue of the day: health care reform.

Of course, the issue is not so much health care as health insurance. The insurance company practices of rescission (canceling your policy when you get sick) and pre-existing conditions (if they suspect you might eventually need health care, they deny your application for coverage) must, Speier said, be forbidden. She also supports the "public option" -- the watered-down compromise (a proposed government-created non-profit health insurance provider, a distant second to genuine single-payer health care) but perhaps the best we can get -- on which President Obama is backing down, under pressure from the richly-funded Big Pharma/Big Insurance lobbyists and from the partisan, conservative talk show-driven agitators.

Rescission: no; pre-existing conditions: no; public option: yes. Speier gets it!

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How Do Italians Pay for It?

In 2008-2009 I am living in Italy and learning a lot. Italy has much to be proud of, including a health care system that in recent years has improved in quality to match that of nearly any western country. In addition to its quality of care, the Italian system is commendable for its equality of distribution; for all Italians (and often foreigners, too) most procedures are covered. Tests and prescription drugs demand copayments but primary care and inpatient care are free.

The Italian National Health Service was established in 1978 by law number 833 (the Riforma Sanitaria) whose preamble states that health care is a human right and is to be delivered equally to all citizens.

However, the way public health care in Italy is paid for is less fair. Most of its funding comes from a payroll tax that is regressive; regular employees bear a disproportionate burden. The other sources of funding are the income taxes and value-added (VAT) sales taxes collected by the federal and regional (regioni) governments. Equity of taxation is one of the most contentious issues in Italian public life and is, in my judgment, the one most responsible for the resurgence of power of the right wing and Berlusconi.

From the provider standpoint, too, the medical system is far from generous. Compensation received by physicians and other providers is based on capitation and is low relative to that of providers in most western countries and also relative to workloads. Doctors here work hard!

Neither is the economics of Italian health care kind to hospitals. Public funding of health care is doled out by the regioni. The Lazio regione (which includes Rome, where I live) has for the past decade run an annual health care budget deficit of 1 billion Euros. Hospitals are paid according to diagnosis-related group (DRG) formulae, as is done by Medicare in the USA. Today, hospital budgets are shrinking and several of Rome's most prominent are closing for lack of funding. Sept. 25, 2008 police presence at a sit-in
	    protesting the closure of San Giacomo hospital in central Rome For example, Forlanini hospital, one of Europe's most technologically-advanced and, in recent years, the recipient of substantial infusions of capital for equipment, is slated to close in March of 2009 for lack of operating funds. My friend Maura who is a nurse on a respiratory rehab unit there says she no longer has most of the drugs in the usual formulary to dispense to their patients; patients are receiving inferior care due to the cutbacks.

Another is San Giacomo hospital (including its reknowned orthopedics unit) in the center of Rome, which just last year had a 15 million Euro upgrade. (In the photo: Sept. 25, 2008, police presence at a sit-in to save San Giacomo. Note the protest banners.) There is considerable outcry in the Italian press but recent changes in governmental priorities make these and other closures appear inevitable. This is a great detriment to the healthcare options available to Romans and Italians nationwide.

For an even less sympathetic view than mine, see Tanner (Cato Institute), The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World (but see below for my opinion on those Cato whack jobs.)

For overviews of the economics of health care in other countries, see Healthcare Economist.

For Italy in particular, see Health Care Around the World: Italy.

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Google logo
Google Health knows when you're sick

November, 2008 -- Google has discovered that it can detect influenza outbreaks and other "...snapshots of what's on the public's collective mind" by mining aggregated search data. Using this data, they are several days ahead of the federal Center for Disease Control (CDC) in detecting disease trends. In other words, when people get sick, they search for terms like "flu symptoms" and many more. And Google is paying attention.

You, too, can stay atop these trends via Google trends. Watch flu trends and more... As Google says, "Google search isn't just about looking up football scores from last weekend or finding a great hotel for your next vacation. It can also be used for the public good."

Do you agree? Draw your own conclusions.

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How Do Americans Pay for It?

In America, most health care insurance premiums are paid by employers. Workers receive them as a job benefit. There are several problems with the American scheme.

The first problem is that the cost to employers rises with each new employee they hire. (Increasingly, this cost is also born by the employee who today is often asked to share it, but that is a topic for another discussion.) Thus, it is a kind of employment tax.

Enlightened tax policy is driven by decisions about activities that, for the good of society, we want to discourage. For example, we have sin taxes to discourage consumption of tobacco and alcohol. Employment is not one of those! We want to encourage employers to do it! Thus, if we could find another way to fund health care in America, we could have more jobs. Who would argue against that?

Another problem is that in this system only employed people (and the relatives thereof) are covered. When the economy is strong and provides full employment, coverage almost suffices but in leaner times, even more are left out. Indeed, no one must be left out, in lean times or good.

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When is health care reform not health care reform?

When it's a snow job. (Thanks to Ron Knox, Sun, 07 Jun 2009, for this item.) See: How Pharma and Insurance Intend to Kill the Public Option, And What Obama and the Rest of Us Must Do.

Note the new term of art... we no longer talk about a "single payer". Now it's "the public option."

Senator Olivia Snowe, "...well-respected and considered non-partisan, and [who] therefore offers some cover to Democrats who may need it" has proposed a Byzantine set of conditions under which "the public option" can take place and probably won't. In other words, she and her cronies can look like they're fixing our desperately broken system while in reality defending Big Insurance/Big Pharma's hegemony.

Robert Reich has it right: "Big Pharma and Big Insurance are gaining ground in their campaign to kill the public option in the emerging health care bill."

It's time for Ms. Snowe to get out of the way and for government to step in and make sure we all get the health care we need, at prices we can afford, paid for fairly and equitably. No Snowe jobs!

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Unfair Advantages? Now We're Getting Somewhere!

In a Jan. 16, 2009 Herald Tribune article entitled Bipartisan Reform Vowed on Healthcare Daschle Calls the System Unsustainable some partisan hack named James Gelfand is quoted as saying, in regard to Obama's plan to reform health care:

"The public plan option is a terrible idea - one of our top concerns in the health reform debate..."
Well, ok, he's not just a hack, he's senior manager of health policy at the United States Chamber of Commerce. And he's a shill for the insurance industry, giving a thinly-disguised defense of entrenched interests. If he'd finished the sentence, it would have been, "It might put some of my clients out of business!"

The article goes on,

...the proposal is anathema to many insurers, employers and Republicans. They say the government plan would have unfair advantages, [emphasis mine] like the ability to impose lower fees, and could eventually attract so many customers that private insurers would be driven from the market.
Um, lower fees? Isn't that the point? Not for Mr. Gelfand.

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Surprised! ...Again

Many healthcare procedures are routine, e.g. immunizations for kids and the every-5-years-after-age-50-colonoscopy. If your doctor is doing her job, these are ordered for you at entirely predictable times in your life. Every American should be getting them. Budgeting and resource allocation for these things can (and should) be rational and planned. Why aren't they? In our present system, they seem to be surprises every time. We must submit lengthy paperwork for insurance claims, argue about what's covered, etc. Ridiculous.

Furthermore, there should be routine tracks for the various chronic illnesses (with variations planned for differing degrees of severity, complicating factors, and responses to treatment) according to plans derived from medical evidence (best practices based on outcomes).

It's silly that the predictable, plan-able procedures should be regarded (from a financial standpoint) the same as the unpredictable ones. Why are the paperwork and eligibility issues the same for a vaccination as for a broken bone?

Money to pay for routine medical procedures should be budgeted for each of us from birth. These procedures should be paid for by a fund that's managed conservatively and whose inputs are known precisely because its outputs are.

A second fund would cover non-routine healthcare, i.e. accidents and acute diseases. The outputs of this fund are known less precisely yet can be predicted by actuarial techniques.

Both funds should be fed from a progressive taxation mechanism. "To each according to need, from each according to ability."

Yet we do none of this. It's hard to believe that we continue to be so financially naive about healthcare!

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A Medical System to be Proud Of? No, One to be Ashamed Of!

How is it we Americans are so brainwashed about our medical care? Why do the candidates for public office tout our system as the world's finest... with straight faces?

"What is particularly shameful is how poorly this country compares with other industrialized countries. In 1960, the United States ranked 12th lowest in the world in infant mortality. By 2004, the last year for which comparative data are available, it had dropped to 29th, tied with Poland and Slovakia." [The New York Times Op Ed piece, Oct. 18, 2008.]

Traditionally, the quality of a country's health care is measured by three criteria:

  • Life expectancy
  • Morbidity
  • Infant mortality
It has been argued that, "...life expectancy and infant mortality are both poor measures of the efficacy of a health care system because they are influenced by many factors that are unrelated to the quality and accessibility of medical care." Nonetheless, health care outcomes in America remain unacceptable.

The NYT concludes, "The chief lesson we draw is that the American health care system, despite the highest expenditures in the world, is badly in need of an overhaul."

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Medicine in the Post-Oil World
Strategies for Delivering Medical Care
In a World without Cheap Energy ("Powerdown Medicine")

I'm just getting started thinking about this... And I'm not the only one.

Johnston et al, in Modern Medicine And Fossil Fuel Resources observe that the story of oil in the 21st century is like that of the boy who cried wolf, the point being that finally the wolf did come.

Walter Youngquist writes in The post-petroleum paradigm -- and population:

Reaching and passing the peak of world oil production will be the most important happening in human history to date, affecting more people in more ways than any other event. It will happen, and during the lives of most people now living.
Johnston continues this theme:
Increasing scarcity and expense of fossil fuels will present medicine with great challenges, especially at its high-tech end... Petroleum-based products are used all throughout the medical sector.

Following these lines of thought, various corollaries suggest themselves...

  • High-tech interventions will be available only to a shrinking elite.
  • Community and locality will grow in importance.
  • In medical care, labor will overtake capital (the way it does in the third world).
  • There will be fewer disposables and more reuse. When oil is scarce, plastic is expensive.
  • Let's learn from the Cubans. I intend to travel there. This will be a reverse foreign aid mission -- the evidence says these folks are the experts. (Ahem, I thought of this before Michael Moore did.)
  • It won't be all bad -- if we're smart about it, we'll use it as an opportunity to emphasize lifestyle and prevention. When healthcare technology gets scarce, it will be better not to get sick in the first place.
Lots of work to be done!

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Chronic Disease Management Systems

Technology is not just an expensive frill. Used well, it can make a genuine difference not only in the high-tech hospital but in the daily lives of people with chronic diseases: asthma, diabetes, hypertension, and others. Such tools can help to:

  • Automate recall processes

  • Incorporate risk factors and lab test results in decision-making

  • Enable quality improvement based on data analysis that far exceeds what could until now be achieved only through traditional chart audits.

Here is an excellent article on how these are done at four community clinics.

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Do You Read Me?

I've been blogging lately...

And I agree with what Russell Mokhiber says about "...the war between the American people and the health insurance industry." [SleptOn Magazine, Sept. 19, 2007]

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Eliminating the middle man does not mean "socialized medicine"!

Health insurance is not to be confused with health care. It is a distinct industry. And it is a parasitic one. It is expensive yet it creates no value. We need to shut it down.

Defenders of the status quo use scare tactics (see Krugman, above) to defend their hegemony. But common sense dictates otherwise.

"[This] bureaucracy consumes 31 percent of health spending, versus 17 percent in Canada. The difference translates into $350 billion frittered away annually here, where a million healthcare workers, as well as hundreds of thousands in the insurance industry, spend their days on useless paperwork.

"This waste is a natural byproduct of private insurance. Private plan overhead is eleven times that of Canada's NHI program. Each dollar spent on private premiums buys only 78 cents of care; the rest pays for insurer's marketing, underwriting, utilization review and profits -- and for the billions paid to their CEOs. Fragmented coverage also means duplication of claims-processing facilities and mountains of paperwork for doctors and hospitals, which must deal with multiple insurance products each with its own eligibility rules, co-payments, referral networks, etc. -- tasks that are absent in Canada. Our multiplicity of insurers also precludes the payment to hospitals of a global, lump-sum budget. In Canada, global budgets obviate the need for most hospital billing and much of the internal accounting needed to attribute costs to individual patients and payers."

The Nation, April 14, 2008.

Cartoon by my Dad, Charles Keller.
(Yes, that's Jimmy Carter...
Our health care dysfunction is not a new problem.)

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Yes on California Senate Bill 840!
September, 2008 -- Leading the nation (ahem, ahem) California is poised to make healthcare history. If our Governator doesn't get in the way. Again.

Up for a vote soon in our state legislature will be Senate Bill 840, crafted by State Senator Sheila Kuehl.

It proposes to replace the existing expensive and dysfunctional private health insurance scheme -- what you have if you're well-off in America -- with a State-administered one.

No doubt the powerful insurance lobby and media machine will trot out the tired nostrums about socialism, government inefficiency, and the boogeyman of state-run healthcare.

The truth is that around 25 cents of every dollar we spend on healthcare goes to the insurance company bureaucracy, not for medicines, hospitals or doctors.

If we're concerned about rising costs (and who isn't?) then eliminating this overhead is an obvious strategy for cost control.

Furthermore, the federal Medicare program -- one of the most popular public programs of all time -- has proven that in overseeing the delivery of healthcare, government can be both effective and efficient. Medicare recipients (my parents, for example) are pleased with their care, and the overhead is less than 2%.

Of course, if you're not well-off in America, then what you have for healthcare is zilch.

Yes, emergency rooms are required by law to serve everyone who walks in the door. But it is undeniable that there are two tiers of patients -- I have worked in several hospitals and I've seen it with my own eyes.

Patients without coverage really do get inferior care. The incentive to the hospital to push those patients back out the door is irresistible. If the hospital is lucky, some county money will help cover the cost. More likely, the hospital will eat it itself.

In the end, we all pay because the hospital must charge its paying customers enough to stay in business. And this is the second breakthrough offered by SB 840: universal coverage.

Similar bills have twice before been passed. And twice our Governor has vetoed them.

Why would populist Governor Schwarzenegger oppose such an obviously smart move for the people of the State of California? To save the jobs of his insurance company friends and their powerful lobbies in Sacramento (our state capital).

Let's hope that this time the legislature will override him. And let California lead the country with a healthcare system that is affordable yet leaves no one out.

Postscript: With little fanfare and barely a mention in the press, on Sept. 30, 2008, Governor Schwarzenegger vetoed SB 840. He defended this action saying that he could not support "...a bill that places an annual shortfall of over $40 billion on our state's economy."

Chalk up another one for the lobbyists of Anthem (Blue Cross), Blue Shield, Aetna, Humana, Kaiser, Unicare...

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That Is Sick!

In our sick healthcare system:

  • Amputating a diabetic's foot is profitable.

  • Delivering the preventive care that could have saved the foot loses money.

  • See the January 11, 2006 New York Times: In the Treatment of Diabetes, Success Often Does Not Pay:
    In "...the byzantine world of American health care, ...the real profit is made not by controlling chronic diseases like diabetes but by treating their many complications. Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000."

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No Butts

In my work as a smoking cessation counselor (please see my web site, www.tobaccoteacher.com) I see this short-sighted policy in insurance companies that pay tens of thousands of dollars for radiation and chemotherapy but not mere hundreds of dollars for smoking cessation classes and nicotine replacements (patches and gum). Our own Governor Schwarzenegger in 2005 vetoed (despite my letter) legislation that would have required them to pay for these sensible preventive measures, bowing to their powerful lobbies and their "logic":

"By the time a situation is acute... the insurer, which has been gambling on never being asked to cover procedures that far down the road, has little choice but to cover them, if only to avoid lawsuits, analysts said." [NYT]
In other words, the thinking goes: "We won't pay for prevention because by the time you get sick you'll be somebody else's customer or dead."

This is why healthcare does not belong in the domain of private business. The short-term thinking demanded by performance for stockholders leads to poor decisions like these.

Only public institutions have the capacity to make decisions driven by long-term considerations. Thus, though it's enlightened public policy, spending on preventive care will always be shunned by corporate (private) decision-makers.

Conclusion: Single-payer healthcare is better for our health!

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Paul Krugman

The Medical-Industrial Complex

One of my heroes, Paul Krugman (winner of the 2008 Nobel prize in economics) writes in the New York Times on 7/9/7 regarding Michael Moore's Sicko and the Canadian healthcare system:
For more than 60 years, the medical-industrial complex and its political allies have used scare tactics to prevent America from following its conscience and making access to health care a right for all citizens...

Yes, Canadians wait longer than insured Americans for elective surgery. But overall, the average Canadian's access to health care is as good as that of the average insured American -- and much better than that of uninsured Americans, many of whom never receive needed care at all.

The only things standing in the way of universal health care are the fear-mongering and influence-buying of interest groups. If we can't overcome those forces here, there's not much hope for America's future.

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Homework-O-Matic

Here's my Arterial Blood Gas (ABG) Analysis homework-o-matic.

Hey all you fellow-nursing-classmates, have at it!

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Nosocomial Infections

Hospitals are dangerous places. Here are some of the things you can catch there. You probably wouldn't catch them anywhere else... and the probability there is surprisingly high. Only recently have a very few hospitals begun to report the rates of these infections. Such reporting should be required!

  • Ventilator-associated pneumonia

  • Bloodstream infections caused by catheters

  • Methicillin-resistant staphylococcus aureus (MRSA) -- Causes an "alarming number of infections and a very significant number of deaths." This bug kills more Americans each year than does HIV. The primary vector? The unwashed hands of healthcare workers.

  • Surgical site infections

  • Clostridium difficile ("C-diff"), a bacterium that causes severe colon infection and stomach pain

And infections are only part of the story. Here are more preventable bad things that happened to hospital patients (in California during the period July 2007 to May 2008 as reported by the Los Angeles Times on 6/30/08):

  • Severe bedsores (466 patients)

  • Foreign objects such as surgical equipment left inside (145 patients)

  • Died under anesthesia (34 patients)

  • Wrong procedure or operated on the wrong body part or patient (41 patients)

This is not to blame the caregivers or the organizations in all cases; it's to point out that the delivery of healthcare is complex and near-impossible to do with total reliability. There are no easy solutions.

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Paradigm shifts are happening and quality is rising.

Here, excerpted from Reflections on Nursing Leadership (Fourth Quarter 2005) is the most succinct statement I've seen of...

Healthcare's shifting paradigms

From process orientation (what professional is doing)
To outcomes orientation (value of what professional is doing)

From focus on provider-patient relationship
To focus on work setting as a learning organization

From do no harm as an individual responsibility
To safety as a system concern

From caregiving that is time and place bound
To caregiving with time and place limitations removed

From focus of care that emphasizes patient compliance
To focus of care that emphasizes best practices

From workarounds being the norm
To crucial conversations being the norm

From decision making based on training and experience
To evidence-based decision making

From organizations that encourage professional silos
To organizations that encourage interdisciplinary collaboration

From seeking cost reductions
To continuously decreasing waste

From emphasis on discharge planning
To emphasis on lifestyle change

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Neurosurgery Mission to Vietnam

I've been helping Dr. Gary Heit to run his nonprofit, Americare Neurosurgery International.

In March, 2008, we ran our third medical mission, this time to Hue, Vietnam.

Quite literally, we saved lives. Gary is an amazing neurosurgeon!

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Obama Gets It!

In a January 8, 2009 article, Health Data Management reports:

In a major speech on Jan. 8 to push his forthcoming economic stimulus package, President-elect Barack Obama pledged to have all medical records electronic within five years.

"To improve the quality of our health care while lowering its costs, we will make the immediate investments necessary to ensure that within five years, all of America's medical records are computerized," Obama said.

We applaud!

The image on the left was not associated with the Health Data Management article; it is included here for your amusement. It is an example of the disinformation and fear-mongering -- much like the entrenched interests did to Hillarycare -- that is being ramped up once again by the forces that continue to oppose (for narrow self-interest only) these moves toward progress. The unspoken sub-text is beware (so-called) socialized medicine.

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Kucinich Gets It!

"Health care for all," he says.

"Insurance companies make money not providing health care. As the co-author of HR 676, a universal, single-payer, not-for-profit health care system, Medicare for All, I understand millions of Americans want health care that is accessible and affordable."
Medicare for All -- what a concept!
"Medicare for All will help businesses large and small, create jobs as well as save the jobs of thousands of people including those of doctors, nurses and other healthcare workers who are currently leaving medicine because it is run by the insurance companies. 1 in every 3 dollars of the $2.4 trillion spent annually in America for health care goes to the insurance companies. If we take that money ($800 billion in unproductive wasteful spending) and put it directly into care, we will have enough money to cover everyone. We are already paying for Medicare for all, but not receiving it. HR 676 changes that!"
He also proposes to end the Medicare Part D boondoggle and go to the heart of the problem: getting drugs to the people who need them:
"[I have proposed a] Prescription Drug Benefit for Seniors, HR 6800, the MEDS Act, which provides a fully paid prescription drug benefit, under Medicare, for all seniors. I wrote this bill to help alleviate the economic pressure that comes from the high cost of prescription drugs. We can pay for it by letting the government negotiate drug prices with the pharmaceutical companies as well as by permitting re-importation."
Hard to believe that this is considered radical... It's common sense to me.

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Gore Gets It!

And not just about the environment. Here he is, speaking in favor of universal health care coverage. Go Al!

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Gavin Gets It!

Mayor Gavin Newsom has launched a program that makes me proud to be a San Franciscan. In his words:
We are still the first and only city in America on its way to universal health care. Our Healthy San Francisco program has already enrolled nearly 30,000 previously uninsured San Franciscans into a comprehensive health access program. While the state and nation falter on health care - San Francisco is showing the way.
But there's more. In my opinion, the most radical aspect of this program is that it provides health care, not health insurance. In other words, our public health service in San Francisco funds the providers directly. No middlemen! Brilliant!

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That's right. You don't.

Who does? Usually, the hospital, clinic, or doctor who created the data.

In other words, not you.

Here is an excerpt from Physician's News Digest, March 1999:

Underlying the entire health care informatics industry is the basic issue of who owns data and how data may be used by others. There is limited public law on this question and parties almost invariably address the issue as a matter of private agreement. Generally, the law in most states gives ownership of the medical and business records to the provider who creates the records, subject to a general duty of confidentiality and in some states a right of access for patients to their own records.
These issues are partly addressed by the Federal law known as HIPAA, the Health Insurance Portability and Accountability Act of 1996. It says that you have these five rights regarding your medical records:

  1. An unconditional right to be informed of the data-handling practices of medical practitioners and providers;

  2. The right to request, but not necessarily to always obtain completely, the privacy protection of your healthcare information;

  3. The right to review and copy your medical record;

  4. The right to request that inaccuracies in your record be corrected; and

  5. The right to know who has accessed your medical records in the past.

The text of the HIPAA law can be found at the US Department of Health and Human Services. It does not actually discuss ownership of medical data, only access to it and control of it. Decisions about ownership are left to the states.

Kate Jackson writes in Whose Medical Record Is It, Anyway? in For the Record magazine:

It may vary somewhat by state law, but the healthcare record is owned by the healthcare provider that created it... [You] generally have the right to see and request a copy of [your] entire medical record. The exceptions to that rule are records pertaining to psychiatric conditions, HIV status, and mental health care... [complete list] most states consider psychiatric records to be "hyperconfidential".
And they can charge you for making the photocopy... of their data.

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Go Aussies!

Imagine having the peace of mind that comes from knowing that you can always afford health care, that your insurer can never cut you off (or deny you coverage in the first place) if you get sick (and expensive) or they suddenly "discover" a "pre-existing condition." This is insane! Life itself is a "pre-existing condition"! Imagine that, no matter what, you could always have the healthcare you need. They get it in Australia. Go Aussies!

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Beat It

Some heart sounds for our nursing class to learn.

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Higher Education: Revolution Needed (Sept. 2005)

The teaching that's done in colleges and universities stinks!

I offer some solutions.

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USHealthCrisis.com: Another One for Francine

In yet another brilliant move, Francine Hardaway has created USHealthCrisis.com, a web site whose purpose, in her words, is to:

...bring about health care reform. If you have a story [about a failure of the US healthcare or health insurance system] please post it to the site, and tag it patient, provider, or payer. We are aggregating this information and will take it to the Obama administration. Right now, reprepresentative stories will be a big help.

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Getting Clear about Single Payer

Francine Hardaway writes a fascinating and often brilliant blog in which the topics are sometimes medical:

Rarely do I disagree with her, but I did when, in 2007, she wrote:

I don't think we will accept a single payer system, because that's just another way to say "rationing health care."
Here's my reply.

What does "single payer" really mean? The significance of the number of payers is that when there is more than one, the incentive structure changes. The rewards no longer go to those who provide prevention and care. They go to those who stick the other guy with the bill.

We already do have rationing, Francine. Every country and every system has rationing; it has to. There's always a gatekeeper (as it's called in the UK, where health care is provided primarily by public funding.) Why ration? Because resources are finite.

Many people are frightened by the idea of gatekeeping by governmental agencies. Consider, though, that the activities of government are subject to the scrutiny of we who elect them; they don't have the impunity of corporations that operate behind closed doors. Corporations are beholden primarily to stockholders. To them, doing a good job means increasing the dividend each quarter. Over corporate officers and management the public has even less control than they do over governmental officials. As long as we have a democracy, I prefer that gatekeeping be done by government, thank you.

The problem with our system is that with multiple payers, we have an additional, unproductive layer of bureaucracy -- all those insurance company claims adjusters who do their jobs "best" when they deny treatments, drugs, and care. They're not evil people but what they do is evil because the incentives are wrong.

Insurance companies add 15-25% (depending on whose numbers you use) to the cost of our healthcare. Yes, there must be rationing. But the rationing process needn't be so expensive.

Eliminating these middlemen is unlikely, alas. They command huge resources and their lobbies are powerful. To protect their bottom line, they run vast disinformation campaigns and promote myths such as the one Francine has voiced. And their job is to ration.

But don't take my word for it... Here is an op-ed piece from the New York Times on March 28th, 2006: U.S. Should Implement Government-Sponsored, Single-Payer System.

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The Electronic Medical Record (EMR): Still Waiting

Rates of adoption of EMRs in the United States continue to be abysmal. Here are some recent numbers (per the California Healthcare Foundation's Snapshot: The State of Health Information Technology in California, 2008):

  • Just 12% of California physicians use alerts to warn them about potential adverse drug events, receive electronic warnings about abnormal lab results, and send reminder notices to patients about regular or preventive follow-up care.

  • Only 25% of hospitals are using bar-coding technology fully for tracking lab specimens and only 13% have implemented EMRs.

  • Many patients do not communicate with their physicians online because they are concerned that on the Internet their privacy might be compromised.
Nearly three-quarters of medical groups in California continue to rely on paper records. Healthcare information Technology (HIT) offers substantial, well-documented benefits both to reduce costs and to increase quality. Why aren't we using it?

The EMR has always been a focal point of my career. When I graduated from UCSF in 1983 with an MS degree in this area (having built a rudimentary EMR for my master's thesis) there were no jobs where I could put these skills to work. But that has changed. Today medical informatics is an industry. For example, both of my recent hospital employers -- Sutter Health and Kaiser Permanente -- have huge EMR implementation projects underway. Several doctors I know are investigating EMRs for their offices. However, industry-wide standards remain largely absent and paper charts remain the norm.

We're still waiting for the revolution.

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Doesn't Compute

One of the places where I have worked as a volunteer was a post-op and orthopedic floor high up in a tall tower in a hospital that shall remain nameless.

In this hospital (and, I suspect, in most) the manual, paper-based procedure for reviewing and renewing medication orders is stunningly labor-intensive and error-prone. This is a task for which computer implementation would be ideally suited. It is astonishing to me that this hasn't been done.

Here's how it works today: In the MAR (Medication Administration Record) portion of a patient's chart there are two sheets:

  1. PRN (drugs administered on an as-needed basis) and One Time Medication Record
  2. Routine Medication Record.
Each has seven rows (one row for each medication that has been ordered) and five columns (one for each of five days, e.g. Oct. 5-10). In each cell, the nurse records the administration of a med on a date. (For meds that are administered several times per day, the cells can accommodate several entries.)

On each fifth day of each patient's hospital stay, the nursing station secretary must see that the form is full and must complete a new form, copying from the old one all the following information:

  1. Patient allergies and contra-indications
  2. All the drugs, their routes, dosages, schedules, and formulations.
The probability of error is high, so the work must be checked by a nurse.

The only possible reason I can see for lack of automation of this procedure is to guarantee that it periodically gets a pair of eyes to review the medication orders. But are the secretary's eyes qualified to perform this review? Is five days the right review period or just the number of columns that fit on the page? Is the labor cost justified? Have errors ever been caught this way? If indeed there does appear to be something dubious about a drug order, is there a mechanism for having it reviewed (and perhaps modified) by a doctor, especially the doc who made the order in the first place? I suspect the answers to these questions are mostly no.

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Providing Emotional Support

Another place where I volunteered at length is San Francisco's HIV / AIDS/ HepC Nightline, a department of San Francisco Suicide Prevention. It is a telephone-based emotional support service.

To become qualified to deliver this service, lengthy training is required -- a couple of months of weekly evening classes. The work itself is surprisingly challenging but uniquely rewarding and I learned a lot.

One of the big lessons was to listen without attempting to problem-solve. You can't problem-solve over the phone but you can listen and often that's the best therapy in the moment. People who are struggling need an ear that hears them. It's something that's in surprisingly short supply. And there was lots more. Here are my notes and observations.

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Don't Just Protect Me, Put Me in Charge!

Privacy will always be a major concern regarding medical data. One of the ways in which patients will be empowered by EMRs/PHRs is by having explicit control over access. While HIPAA goes a long way toward protecting privacy, it leaves the actual enforcement in the hands of the caregivers and their institutions. Under today's system, the patient is protected but not in control. This must change.

Here are the aspects of personal health records generally considered most sensitive:

  • HIV or AIDS
  • Mental illness or any mental health condition
  • Alcohol or substance abuse
  • Sexually transmitted diseases
  • Pregnancy
  • Abortion or other family planning
  • Genetic tests or genetic diseases

With the electronic medical record system we need, the patient will be the owner of the data (see What Do You Mean I Don't Own My Own Medical Data? above) and will have complete control over who sees it and which parts are withheld from whom. In other words, don't just protect me. HIPAA does that and that's good but it's not enough. Put me in charge! Let me decide where that data goes... and doesn't go.

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Health Sites

In a January 7, 2009 article, the Wall Street Journal reports on a crop of new and increasingly useful web sites for people seeking (and collecting and sharing) information about health care, especially their own. These include:

The article offers a good collection of links and brief site reviews for the informed patient.

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Google Gets It

Google says (and I do not doubt it) that the most commonly-sought information on the Web regards health. So it's a no-brainer that their business should do a good job of helping their users find what they seek.

Though medical data searching is huge, what's at stake is even bigger. The data to be managed is not just generic -- diseases, treatments, research, institutions, services, etc. It's also each of our personal medical histories, status, progress, and plans.

She who controls the data controls the process.

Empower the patient.

And be the supplier of that power. Thus, Google Health.

Great strategy!

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Help for Nurses On the Job
In my two years of nursing training I learned many things. One was that it's a hard job, sometimes unnecessarily so. Here's one of my ideas about how to fix that.

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The Art of Volunteering

In the years leading up to my nursing school stint, I volunteered in lots of San Francisco hospitals, clinics, and healthcare services. You don't just walk in the door and magically transform lives... There's an art to it. Most important are the things that -- even with the best of intentions -- you must never do. A volunteer must never:

  • Do anything invasive
  • Give medical advice or information to a patient or family
  • Give food or water without authorization
  • Tell a family that a patient has died
  • Make judgements about lifestyle, esp. domestic violence
  • Handle controlled substances
  • Help break up a fight or restrain a patient
  • Do schoolwork in the ER
  • Read medical records

Here are more thoughts on my experiences as a volunteer...

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Pritikin's Still Got It!

Concerned about health, fitness, longevity, weight loss?

Pritikin is the diet that works. Here it is in a nutshell.

  • Choose foods that are big in size but small in calories. Avoid calorie density.
  • Choose unrefined carbohydrates that are naturally rich in fiber and water: fruits, vegetables, beans, whole grains.
  • Avoid high-fat foods, especially those with saturated fats like meat and cheese and those with refined sugars.
  • "Eat" your water, that is, fruits and vegetables.
  • Protein should not exceed 10-15% of diet (3 oz, size of deck of cards). Use meat for flavor, not as the main bulk of a meal.
  • Sugars, added and natural, should not exceed 10% of diet.
  • Salt: less than 2000 mg daily.
  • One hour/day of moderate exercise, e.g. walking.
These practices and principles are borne out by experience and research. Here is some perspective.
  • The World Health Organization of the United Nations (WHO) recommendations are very similar to Pritikin's.
  • Compare it to, for example, the Atkins diet (high fat, high protein). Atkins (and most others) are discredited by research, but popular because it gets initial results quickly and people like to be told to eat meat and cheese.
  • The global epidemic of obesity, heart disease, and chronic disease is due to:
    • Western-style staples like red meat and dairy, vegetable oils, sugar-rich drinks and sweets, and salty snacks replacing traditional, closer-to-nature staples like beans, potatoes, corn, and fresh vegetables
    • Sedentary lifestyles
The Pritikin program has 30+ years of experience. Their track record is unmatched -- this is the real deal. Check it out... and get healthy!

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Are we getting the message about health and personal responsibility?

Here is a gem I found on the web... people really do eat at the Heart Attack Grill.

They even have cigarettes on the menu!

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Cato Schmato

Want to set your teeth on edge? Read the "scholarly" writings of the whack-jobs over at Cato. These are no more than industry-sponsored puff-pieces:

  • Exxon-Mobil, Shell Oil, Tenneco Gas, Amoco Foundation, Atlantic Richfield Foundation, Chevron Companies, and the American Petroleum Institute re: global warming "myth"
  • Philip Morris, R.J. Reynolds re: "smokers' rights"
  • Other sources of funding include Bell Atlantic Network Services, BellSouth Corporation, Digital Equipment Corporation, GTE, Microsoft, NYNEX, Sun Microsystems, Viacom International, American Express, Chase Manhattan Bank, Chemical Bank, Citicorp/Citibank, Commonwealth Fund, Prudential Securities and Salomon Brothers.

Writings on the medical system are sponsored by the pharmaceutical industry (Eli Lilly, Merck, Pfizer). The intent is to influence policy under the guise of researched wisdom. Don't vote for any politician who can't see through this sham!

For example, an article on healthcare funding, Socialized Medicine is Already Here, reveals its bias in the title; "socialized medicine" is derogatory and no one would choose anything with that name. It's like Bush saying about Iraq, "We want victory, not defeat!" Well, duh.

In high school, we learned to call such statements tautologies, vacuous statements that set my teeth on edge. Now let's get to work on the real issues.

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Getting It Explained?

Do you know what your insurance covers? Do you understand the invoices you get from your hospital or your provider? Do you understand the EOB (Explanation of Benefits) your insurance company provides when you make a claim? Have you actually read your policy? If you have, did you understand what you read? Did it give you confidence that your medical needs would be met? When you go for medical care, do you know what you'll be charged out of your own pocket? Or do you cross your fingers and hope for the best? Can your doctor (or your doctor's receptionist) provide clarity on any of this? Do you even bother to ask? Have you ever tried not to pay an insane medical bill? Have you seen what that does to your credit rating?... And then tried to buy a car or a house or get a credit card? Why is any of this OK?

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Vaccinate!

Ever seen a list of all the vaccinations in one place? Useful! Here they are... Among medicine's greatest achievements.
  • Diphtheria
  • Tetanus
  • Pertussis
  • Poliomyelitis
  • Haemophilus influenzae type b - Hib
  • Measles
  • Mumps
  • Rubella
  • Varicella
  • Hepatitis A
  • Hepatitis B
  • Influenza
  • Pneumococcal Disease
  • Meningococcal Disease
  • Human Papillomavirus
  • Rotavirus

The details about these and lots more excellent information for practitioners about vaccinations (is it possible they aren't taught this stuff in med school?!?) can be found at docsimmunize.org. This valuable web site is run by Terri Olson, RN (wife of Pat).

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Pat Rants

My lifelong pal Pat Olson has had a distinguished career as a US Navy flight surgeon. He learned much about "...a practice of socialistic medicine called the US Navy."

He goes on:

Does it promote itself as socialistic? Obviously not. Is it a perfect system? Obviously not. But even its critics admit that with access to care for servicemembers and their families regardless of rank or ability to pay, in terms of objectively verifiable outcome measures it betters the US private sector.

This leads me to something I see as the Dark Side of medical informatics. As long as we have a 'pro-competition' insurance industry, rewards will go to those who cherry-pick. Beyond HIPAA, you've got the specter of cyber sleuthing medical records for the familial trait here, the genetic deletion there, that incurs increased risk. It terrifies me to think of a child being denied care because of something in a record somewhere and broadcast unknowingly to the wolves of the insurance industry.

Okay, I'm outta control...

But we agree, Pat, we agree.

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Here's all about me personally.
Updated Sunday, 21-Aug-2016 19:54:14 EDT

 

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