Vol. 191 April 15, 2018 The Gun Violence Epidemic

April 15, 2018

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“EPIDEMIC” continues to be a common catch word for headlines. Apparently we have lots of epidemics; the flu, HIV, opioid, Zika, gun violence, etc. We spend a lot of tax money investigating and containing epidemics. . . . Oh, . . . all except for that last one: gun violence.

Why is that? In 1996 the Communicable Disease Center (CDC), our federal bulwark against harmful epidemics, was expressly instructed by Congress NOT to study anything related to guns, i.e. don’t give research grants, don’t establish data bases to track events, and don’t sic the EIS on the gun violence epidemic. In one of his rare Executive Orders President Obama instructed the CDC in 2012 to resume their gun violence research and asked Congress to allocate $10 million dollars for that purpose. Congress never did.

EIS stands for the Epidemic Intelligence Service, a division of the CDC. It has a stellar reputation for laser-focussed field analysis of incipient epidemics to guide early actions to contain them, to reduce any harm to people. Just last week the CDC launched an investigation into a cluster of 53 new HIV cases in Lowell, MA. (In 2007 Boston had a “cluster” of 92 gun-related homicides.) Ironically, the CDC remains hamstrung in any effort to collect and analyze data on the gun violence epidemic at a time when it is asking the general public to participate in identifying any other kind of potential epidemic via internet “crowd sourcing” .

The CDC does keep mortality statistics and issues an annual report of causes of death for each state. The difference of gun-related death rates  between states is huge, and  no one really knows why. Massachusetts had the lowest number of gun-related deaths in 2016: 3.4 deaths per 100,000 population, or 242 gun-related deaths in Massachusetts that year. Texas, Florida, and California had 3,353, 2,704, and 3,184 gun-related deaths respectively that same year. Those three states also had the most suicide deaths and the most accident-related deaths of all the states. That’s interesting, but those rates may not be related in any way to each other . Food for thought? Too bad the CDC can’t collect more data on gun deaths.

A gun is the harmful agent in this epidemic just as a virus is the harmful agent in the AIDS epidemic. True, human behavior is the cause for both of the epidemics spreading, but while we are developing a HIV vaccine we have implemented effective measures to contain the epidemic with “safe sex” campaigns, identification of risk factors, pre-natal treatment of HIV-positive pregnant women, early treatment of exposed newborns, and development of successful medical treatments. All of this was accomplished with the support of the CDC and NIH. Why not provide government support for similar interim steps to reduce the gun violence epidemic? Medical societies and many citizen groups have picked up the “safe gun” banner. Why hasn’t the federal government done so?

One answer is, of course, money. The NRA contributed money to 205 House members (189 Republicans and 16 Democrats) and 42 Senators (35 Republicans and 4 Democrats) in 2012. The Democratic Senator that got the most NRA money got less than the 41 Republicans above him or her on the list. 95 of the top 100 NRA money receivers in the House were Republicans. Most analysts actually consider this as “chump change” ($5,000-10,000 per Congressman) compared to the $18.6 million that the NRA spent on NRA-favorable candidates in the 2012 elections. Analysts speculate that the money buys “allegiance” rather than “influence” (whatever that means). We all know it buys lots of “thoughts and prayers.”

Another answer may be that there are more guns than people in the U.S. It is as if everyone had AIDS, or as if HIV- infected people considered it their constitutional right to do anything with it they wished to. We as a nation did a lot to reduce the harm of HIV without abolishing the HIV virus. Why can’t we take the same approach to gun violence? We could do quite a bit without abolishing guns if we could do research about how guns are spread, how they are used for harm (In fact, 50% of gun deaths are suicides), how we could reduce harmful use (electronic signatures, smart guns, trigger locks, no multiple cartridge magazine, etc.).

The significant reduction of auto accidents deaths was accomplished by multiple means (seat belts, car seat regulations, air bags, electronic sensors, changes in car manufacture, speed limit regulations, etc,) and not by abolishing cars or drivers’ licenses. With better data perhaps we could take effective action to reduce the gun death epidemic.

Claritin:gun cartoon

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Vol. 189 March 15, 2018 Future Medical Breakthroughs

March 15, 2018

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Some predictions from the internet (“fake news?”) and some from investors ( “real news?”)

 

This first set of predictions, though reported on the internet, is from an interview with the CEO of Mercedes Benz who listed Tesla, Google, Apple, and Amazon as his current competitors, not other auto companies.

The Tricorder X price will be announced this year:  “There are companies who will build a medical device (called the “Tricorder” from Star Trek) that works with your phone, which takes your retina scan, your blood sample, and you can breathe into it. It then analyses 54 biomarkers that will identify nearly any disease.  It will be cheap, so in a few years everyone on this planet will have access to world-class medical analysis, nearly for free.  Goodbye, medical establishment.”

3D printing:  “The price of the cheapest 3D printer came down from $18,000 to $400 within 10 years.  In the same time, it became 100 times faster.  [3D medical devices like heart valve replacements are already being used in some major medical centers] All major shoe companies have already started 3D printing shoes.”

Alternative protein source:  “There are several startups that will bring insect protein to the market shortly. It contains more protein than meat.   It will be labeled as “alternative protein source” (because most people still reject the idea of eating insects).”

“All in” on smart phones:  “If it doesn’t work with your phone, forget the idea. There is an app called “moodies” which can already tell in which mood you’re in.  [MGH is currently testing such an app’s ability to accurately monitor cell phone self-reported feelings by high-risk psychiatric patients, so that any imminent suicide action can be identified and treated.] By 2020 there will be apps that can tell by your facial expressions, if you are lying.  [Current face-recognition programs at airports already are used to spot “potential terrorists”.] Imagine a political debate where it’s being displayed when they’re telling the truth and when they’re not.”

Longevity:  “Right now, the average life span increases by 3 months per year. Four years ago, the [U.S.} life span used to be 79 years, now it’s 80 years. The increase itself is increasing and by 2036, there will be more than one year increase per year.   So, we all might live for a long time, probably way more than 100.”

That’s it for the “pie in the sky” walk, but it’s money that talks. Where is it going?

Lab-cultured burgers
Edible animal protein that is brewed from animal stem cells in a bioreactor has passed the “taste test” for beef, chicken, fish, and duck, so that “this potentially trillion-dollar market opportunity” has attracted several Venture Capitalist funds. MosaMeat, the creator of the first “clean burger”, has received millions of dollars of VC investments. “The biggest challenge is taking what’s in the lab and making it commercially viable.” A pound of Memphis Meat costs about $2,400 to produce in the lab. That is about $600 for a Quarter Pounder. The company aim is to get it down to $5 – a true Value Meal. (Wired March 2018, pg.15)

Surgery-free biopsies looking for cancer
The detection of cancer cells circulating in our blood by identifying bits of cancer DNA shed into our blood by tumors is already used to “personalize” (i.e. adjust type of chemotherapy agents) in patients already diagnosed with cancer.  VC’s are currently investing billions (yes, that is a “b”) in several companies that are racing to develop DNA and genome-sequencing identification technics to detect tiny, currently non-suspected cancers in healthy people, all from a simple non-invasive blood sample.  The hope is to make an even earlier diagnosis of cancer. “Liquid biopsy detection” is still years away from being patient-ready, but it is not lack of money that is blocking sight of these “blood unicorns”; it is basic biology. (Wired, February 2018, pg. 16)

“Transparent Larry” guides robotic operation on real Larry
Larry Samrr (there should be a terminal “t” in his last name, but there isn’t) is an astrophysicist and astronomer at the University of California Davis who has been keeping precise records of his intake, energy output, and excretions (another output measure) for years. That data along with periodic MRIs, frequent blood and stool analyses, annual colonoscopies (real and virtual), and complete DNA sequencing (genome identification) data has been entered into a super computer at the California Institute for Telecommunications and Information Technology, (Calit2).  The super computer produces a constantly-updated 3D image of Larry’s insides, “Transparent Larry.” The computer made the diagnosis of Crohn’s disease in Larry way before clinical symptoms appeared. In 2016 it guided the removal of a diseased portion of his colon. The “Larry Transparent” image was fed directly into a da Vinci Xi robot his surgeon was using. It reduced the operation duration by about an hour. “Experimenting with fancy new technology is not always a surgeon’s top priority.” It helped that Larry’s surgeon was from a family of engineers and was immediately intrigued by “Transparent Larry”. (The Atlantic, March 2018, pg.28)

Nanoinfusions of DNA to regenerate, restore, and reprogram cells
Cells can be reprogrammed to do different functions by injecting them with different mixtures of DNA, RNA, and proteins, usually delivered by a virus. Such a method can produce indiscriminate immune responses to the virus, unintended injection into non-target cells, and other undesirable effects. Scientists have developed a tiny electronic chip (“nanochip”) that creates holes by electric current in only a portion of a mouse cell surface, so that a reprogramming mixture can be inserted at a precise dose  without “upsetting” the entire cell (“nanotransfection”). In mice this has allowed skin cells to build new blood vessels to help heal a damaged limb and to restore brain cells damaged by a stroke. “Human trials may begin in a year.” (Scientific American, December 2017, pg. 20)

I see by the old clock on the wall that I have run out of time (I seem to be about an hour late everywhere I go this week for some reason), so I can’t go on about other future medical breakthroughs in wearables, probiotics, medical marijuana, robotics, cryptocurrencies for your health insurance plan, obesity control, understanding teens’ brains, and, of course, many, many more apps.


Vol. 188 March 1, 2018 St. Valentine’s Day Massacre #2

March 1, 2018

Hub thumbnail 2015St. Valentine’s Day Massacre,
Chicago, Ill. 1929:
7 gangsters killed.

St. Valentine’s Day Massacre, Parkland, Fla. 2018:
17 kids & staff killed.

Firearm safety is a public health issue”
-Massachusetts Medical Society, February 2018

The 1929 massacre was partly responsible for the 1934 Illinois and 1935 Federal laws regulating machine guns. The laws actually did NOT ban the guns, They taxed them! The tax was $200 (about equivalent of $8000 today) and the annual license to own one was also very expensive. It effectively doubled the price of a tommy gun, the gangsters favorite. In 1986 the sale of fully automatic guns was prohibited by federal law “except those already existing in owners hands” that were grandfathered in. (1)

This year’s St. Valentine’s Day Massacre was the 30th mass shooting (more than 4 victims) in 2018 . . . so far. It was also the 17th time a gun had been fired on school grounds in 2018 . . . so far. AND on February 14, 2018 there were 28 additional gun deaths elsewhere in our country. (2)

Just to numb your brain with some more statistics (I know, I know . . .your eyes are already glazed over having read these numbers or others like them so many times), but during the period of 2009-2013 there were 722 per year firearm-related injuries Massachusetts, a state well-know nothing for its extensive of gun regulations . When you subtract the average of 121 suicides per year and 187 unintentional injuries per year some might say, “Only half are homicides. What’s the big push against gun violence.?”

And that’s when you can reframe the conversation into “gun safety”, not gun banning, not gun restrictions. That is the tack the medical profession is taking, and it might prove to be less confrontational to vested interests and more successful than other efforts.  Gun safety measures target preventing ALL of the 722 annual gun injuries. (pun intended).

The American Academy of Pediatrics strongly recommended a few years ago that pediatricians ask about gun safety as part of their usual assessments of household risks during a well visit; i.e. “If you have guns in the house,are they stored safe from the access of children?” One response was Florida legislature passing a law making it a crime for a physician to ask a patient or parent about gun ownership. The law was rescinded by the US Court of Appeals after the AMA brought suit.

In the same Feb. 24 2018 newspaper that Trump called for the arming of school teachers the Associated Press reported that 9,070 pupils (1 in 105 students) had to be physically restrained in Massachusetts school during the 2016-2017 school year.   244 of those incidents resulted in an injury to student or staff. Nationally the U.S. Education Department estimates that figure of physical restraint is at least 22,000 incidences per year. So, let’s just throw a gun into THAT equation! (CCT Feb. 24, 2018)

A relevant model of effective action is the decrease in auto fatalities by passing multiple laws and regulations, technological advances, and public education (Seat belts, airbags, speed limits, car cameras, etc.)

Smart gun technology  now exists to make guns safe, but they would still allow the owner to “repel any invaders of his house . . . or country”,  and might cut the number of gun injuries by 50%. Reducing mass homicides would require more regulation of automatic guns.

Organized Medicine’s new recommendations are to focus on gun safety.
1. Physicians should talk to their patients and families about gun accessibility, storage, and safety in the home.

2. The CDC should be allowed to conduct gun violence research (collect and analyze data)  like in any other public health epidemic.

3. Increase federally funded research on this “urgent health care crisis” of gun violence.

Many physicians belong to the NRA, “and that’s OK”. A physician friend of mine from Massachusetts was interviewing for a medical license by a physician panel in New Mexico. The chairwoman, noting his home state, asked him if he knew about gun control in New Mexico. He pleaded ignorance, and she responded, “A steady hand. Would you like an application to the NRA?”

 

 


Vol. 187 February 15, 2018 What is Love?

February 15, 2018

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It is a day after Valentine’s Day, a good time to ask, “what is love”?

Is it biochemical, just a roiling internal soup of our neurohormones? You can purchase potent messengers of love derived from that soup, sex pheromones, in various brands of solutions, lotions, and, shall we dare say, “potions” just a click or two away on the internet. Do they exist?

Or is it psychological, just a positive tilt in our balance scale of social experiences? An author on NPR just last week talked about her work on the definition of love, and she just rattled off an excellent one sentence definition: “Love is a collection of multiple positive moments shared with another.” Sorry, I can’t remember the name of her book. More about “multiple positive moments” leading to love later.

Even if we don’t know what love is, do we really know what it does?
Dr. Helen Reiss, Massachusetts General Hospital, lists five effects of love in her book The Empathy Effect.

1) “the honeymoon”
When you first fall in love “your head is in the clouds; you are walking on air.” Both effects are supported by a large outpouring of dopamine, the “really good feeling” hormone. Serotonin, the “mood regulating hormone”, also decreases at the same time which can explain both the ecstasy and the dramas of early love.

2) “the bonding”
As time passes the surge of dopamine subsides and there is an increasing level of oxytocin, the “bonding hormone”. Your neurochemical soup starts getting back into balance, and you approach a more steady state, one more conducive to the “long haul”.

3) “singleness anxiety”
The anxiety and loneliness of being single can lead to increased levels of norepinephrine, cortisol, and epinephrine, the “stress hormones”. Love lost is stress found.

4)  “togetherness medical benefits”
The diagnosis rate of advanced skin melanoma is lower in couples, and diseases with easy bruising are diagnosed sooner in people who are coupled, presumably because each person has another looking at their skin. (So saith Dr. Reiss) Also, each person in a couple may help break through the denial of the other about the need to see a doctor.

5) “Longer lives”
An increased disease protection for coupled  people is not just skin deep. Multiple studies have found that married people have less substance abuse, less depression, and lower blood pressure than single peers. A 2010 review of 148 studies of longevity revealed that increased longevity was associated with any “close social relationship”, not necessarily a romantic one. Family and friends do help.

Which gets me back to that “collection of positive moments shared with another” mentioned in the beginning. What about shared positive moments on social media? Does using Facebook increase your longevity? lower your blood pressure? Does it depend on your number of “friends” or on the number of hours spent on Facebook? What about any Match.com effect on melanoma diagnosis? Will questions like this provoke a new wave of important biosocial research, or will they merely spawn a blockbuster Sci Fi novel (film?) of a woman with 83 million Facebook friends who becomes President and lives cancer-free to 150?

After all, “love conquers all”.
Well, maybe not all of the time and in all of the places. Pakistan just this year outlawed St. Valentine’s Day as a threat of “increasing Westernization”.


Vol. 186 February 1, 2018 Good News For Dieters, and Some Others Who Ingest

February 1, 2018

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“The only time to eat diet food is while you’re waiting for the steak to cook.”  — Julia Child

Pizza, even bad pizza, makes you feel good.
A recent study of 10 men in Finland (there’s the Finns again!) found evidence of high level of natural painkillers in their brains after eating a pizza. Their opioid receptors literally lit right up after the pizza! Even more surprising, the pizza did not have to be good to show that opioid receptor activity. If the same nutritional value was ingested in a “nutritional goo” form, the brains had even more opioid-like activity. So, the pleasurable feeling after eating pizza has nothing to do with how good it was. Speculations abound about a “full stomach feeling” or a “return of energy” as being the cause of the source of release of this endogenous opioid-like substance. (Journal of Neuroscience, November 2017)

Coffee can be part of a healthy diet.
A mega-review of over 200 studies of coffee consumption revealed that coffee consumption was associated with more benefit than harm, at all levels of consumption. Coffee contains more than 1000 bioactive compounds, including antioxidants, so this review was timely. The largest risk reduction of adverse health outcomes was found in those people who drank 3 to 4 daily cups of coffee (caffeinated OR decaffeinated!).  Death rates from any cause,  death rates from heart disease, and death rates from associated cardiovascular diseases were 15-19% lower in coffee drinkers. High coffee consumers had a 18% lower risk for cancer while lower consumers still had a 13% lower risk compared to non-coffee drinkers. The only adverse effects of coffee consumption were found in women: some higher risks for pregnancy loss, more preterm births, more low birth weight infants, and more bone fractures. The editor of the journal, anticipating our excitement at this news, counselled that “clinicians should not recommend coffee consumption on the basis of this review.”  And, oh yeah . . . this mega-review only included studies of black coffee. If you add sugar, milk, or any other ingredient to your coffee . . . “never mind”. (BMJ 2017)

Fecal transplants now come in pill form.
Selected cases of intractable diarrhea caused by recurrent infection with C. difficile (a bacteria that overgrows in the intestine after multiple courses of antibiotics) have been treated successfully by “transplanting” other people’s normal feces (material that contains normal symbiotic bacteria) into the patient’s intestines by infusing liquid fecal material either through a nasogastric tube or a colonoscope. In a study of 116 participants with recurrent, intractable diarrhea 96% were cured by the administration of the fecal material in a pill form. That is good news, but I hope that I won’t ever have to take that pill. (JAMA, Nov. 2017)

Low-dose aspirin does not raise your risk for intracranial bleeding.
A whole lot of people take daily low-dose aspirin (83 mg. – a baby aspirin) in the belief that it will reduce their risk of a fatal heart attack. The evidence actually shows that the preventative effect of low-dose aspirin is true only if you are trying to prevent your second heart attack; i.e.. the data supports its preventive effect in those people who already have clinical heart disease. Much of the general population, including me, is taking low dose aspirin in hope that it will work similarly for them. The only problem is that aspirin is an anti-thrombotic agent (it makes platelets “slippery” so that platelets don’t clump to start a clot). Such an effect raises a concern about spontaneous bleeding, particularly in the brain. A study of 400,000 people over 5 years in an established U.K. database showed that the incidence of brain hemorrhage was not significantly higher in those on the low-dose aspirin compared to those who took none. Remember also that if you have been taking low-dose aspirin for some time and decide to stop, your risk of spontaneous adverse clotting events may increase over the next 6-12 months. (Neurology, Nov. 2017)

Pasta is back!. . .  sort of.
An Italian study (no conflict of interest there I’m sure)  of 23,000 Italians revealed that the pasta lover had lower BMIs, the gold standard for definition of overweight. The researchers tout that pasta is not “just empty carbs”, but contains protein (6.7 grams per cup) and, if whole wheat pasta, it has iron, folic acid, and several B vitamins. The Italian study results are similar to a U.S. study of about 1,800 middle-aged adults, but there are a couple of caveats to consider. Italians eat much less pasta than we do in a meal because they consider it a first course, not the whole meal. The participants in the Italian study consumed an average of 3 oz. (86 grams) of pasta each meal. The study researchers did not name the “ideal amount” of pasta to eat per meal, but did note that those Italians who ate more pasta than the average tended to be obese. As we have said before, losing weight usually comes down to (no pun intended) taking in fewer calories rather than picking different kinds of calories to eat.


Vol. 185 January 15, 2018 New High Tech, Now and in the Future

January 15, 2018

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The start of a new year is a great time to look at some new medical technology and speculate a bit about how it might evolve.  This blog space is too limited to cover the inundation of new medical apps, so we will largely ignore them.

DIGITAL ADHERENCE MONITORING –
The title alone has an ominous ring, and that is not altogether an inappropriate feeling. A pharmaceutical company is testing a pill with a built-in sensory that can track AND REPORT ON whether or not the patient is taking a medication. The sensor is called an Ingestible Event Marker (IEM), which I think is only a slightly less ominous label. The IEM is activated when gastric contents reach it as the capsule dissolves in the patient’s stomach. The activated IEM sends a signal to a patch worn on the patients abdominal skin. The patch, in turn, alerts a cell phone app that reports the event to monitoring physicians. If the patient doesn’t take his medicine, of course, there is no electronic beep from the cell phone to the monitors. This gives the prescribing physician real-time data on the patient’s “adherence” to the prescription (used to be called “compliance”, but that was declared politically incorrect during the peak of concern with patient’s rights and autonomy). The same app can also track patient-reported activity, mood, and quality of rest. This package of new technology is called Digital Health Feedback system (DHFS), and, as you might guess by these tracking elements, this clinical test involved patients with a mental illness, schizophrenia to be exact. As one reviewer commented, “”It is ironic that this technology is being piloted with a drug used for paranoia.” (NEJM, Jan. 11, 2018, pg.101)

We are assured that the use of this technology is completely voluntary, and the patient can remove the reporting patch anytime they wish. A preliminary study of 28 patients using the IEM pill found that 27 completed the study, 24 of them thought that the technology would be useful to them, and 21 said they would like to receive reminders on their own cell phone if they forgot to take the medicine. (Ibid)

Despite the apparent compliance with this adherence pilot test, I can imagine how this might evolve in association with other new technology:
Alexa at 8:00 AM – “Good morning Herbert. Today’s weather is going to be unseasonably warm, you have a 10:00 AM appointment in your office, and be sure to take your high blood pressure pill after you eat breakfast.”
Alexa at 12:30 PM – “Keep up the good work Herb. You have only one scheduled appointment this afternoon, and I notice that you haven’t taken your blood pressure pill yet.”
Alexa at 5:30 PM – “Now Herb, remember that this pill should not be taken with alcohol. I know it must have been a hard day, but you don’t want to make it any harder on your body.”
Alexa at 8:30 PM – “Hey Herb! Not only have you not taken your pill, but I noticed that you skipped your regular visit to the gym today. Wha’sup? By the way, congratulations on your Weight Watchers dinner tonight.”
Alexa at 11:45 PM – “HEY STUPID! You forget to take your pill ALL day. Take your pill NOW, turn off Colbert, and go to sleep. Your family is counting on you, … not that I care, of course.”

VIRTUAL ENCOUNTERS –
Kaiser Permanente, the large California-based health system, reported that last year a majority (52% actually) of their 100 million patient encounters were “virtual visits”. (NEJM, Jan. 11, 2018, pg.104)  Virtual visits involve secure email and video engagements. Patient portals into medical offices, use of Skype, and teledermatology programs are familiar virtual tools. Telemedicine that allows monitoring of blood pressure, weight, blood glucose, and even EKG for home-bound patients with chronic disease are commonplace now. Future innovations could include cell apps that monitor the “total hours spent in high-allergen zones” for an asthma patient, or that deliver “intensive behavioral counseling” to people with obesity-related disease (“HERBERT! Step away from that refrigerator!”), or that make assurances that the patient’s near-empty automated pill dispenser (remotely monitored by the pharmacy, of course) would be filled soon by a forth coming home visit.

One author suggests that in the future “a face-to-face, in-person encounter would be reserved for the patients with the most health care needs – the 5% that account for 50% of costs. In-person encounters would become Option B”. (Ibid)  Obstacles to such progress could be patient fears of getting trapped in endless “phone menus”, lengthy voice message instructions, or numerous, sequential mouse clicking. Physicians might fear being marginalized, and, of course, no one is currently paying for these virtual encounters. A future evolution to mostly virtual visits would require a significant reorganization of and changes in reimbursement of medical care delivery. Kaiser Permanente’s virtual visit capacity is supported by the 25% of its annual $3.8 billion capital budget it spends on information technology.

Though I am tempted, I won’t go into what might happen if a future patient portal, an automatic pill dispenser, and Alexa signals got all mixed up together by mistake. Might a patient request for a 10:00 AM home visit on Tuesday result in 1000 AMbien pills being delivered to the patient’s home by AMazon on two days?

 


Vol. 184 January 1, 2018 To the Dark Side of EMR

January 2, 2018

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“… a fundamental barrier [to successful EMR implementation] that has not received due attention is the disconnect between health IT developers and users.” (1)

I was a solid advocate of electronic medical records (EMRs). Now I am a skeptic.

Primary care physicians are currently paying a big price, in terms of both time and money for the elusive promises of EMRs. As a quality reviewer of hospital medical records, an experienced office-based pediatrician, and a medical director working with an excellent medical staff, I believed that EMRs would really help us to improve the delivery of quality care. I happily jumped on the “evidenced-based medicine” bandwagon and believed that EMR data would help us. After three years of working with two different EMRs in a primary care practice, I have now “gone over to the dark side.” I have slowly realized that EMR “data” does not equate with “useful information” for primary care providers.

I have never belonged to the AMA, for me a “too-conservative” medical organization that I considered primarily a bastion of physician resistance to positive change. A definite sign of my conversion from EMR advocate to EMR skeptic is my agreement with a recent AMA statement by the Executive Vice-President and CEO of the AMA:

“Harnessing the power of health data is an enormous and important challenge, and one that should be led by physicians. The solution must be useful for physicians, and it must allow us to spend more time with our patients and deliver better care.”

Of course, there are all kinds of physicians in all kinds of practice settings, and “one size fits all” does not seem to be working for primary care EMR.

Use of EMR in our office is slowing us down, is decreasing the time we spend with patients and their families, is increasing the chances of provider communication gaps or slips, and has increased the frequency of “work arounds” for the delivery of quality care. “Work arounds” is a traditional quality improvement term that describes the methods that workers in any setting develop to skirt the system problems that hinder them from doing their best job. The presence of “work arounds” is one of the cardinal signs of a dysfunctional system. “Work arounds” often serve as the first target of any effort to analyze quality performance.

So why have I “gone over to the dark side”.
EMR has become way too complicated – There are too many screens requiring too many clicks, too many switches from scrolling wheel to cursor pointer, too many inconsistent navigation routes using tiny icons or miniscule, barely-noticed arrows. To see the basic clinical information I need before entering an exam room with our EMR ,  I need to review 2 or 3 computer screens, make 4 or 5 clicks with the mouse, and both scroll and/or drag with a cursor for the information that I use to be able to read quickly on two facing pages in the paper record.

In the quest for the versatility that is necessary to serve thousands of different physicians in hundreds of different settings, the award-winning EMR we use is awkward and time-consuming for us in primary care. It is driven by the need for reimbursement documentation in specialized (expensive) care settings. Workaround? – I read the paper encounter forms completed by my patients and my staff before I start the patient encounter. It is faster, sometimes more reliable (because there is no absent entry), and is more focussed on today’s encounter than those multiple computer screens which are trying so hard not to “miss” any data, no matter how irrelevant to today’s tasks.

EMRs have too many ways to record information from multiple sources – Valuable patient encounter information from nurses, social workers, and medical assistants can be hard to find in the mass of data. It usually requires purposeful clicking on tiny icons or miniscule arrows (again) on multiple screens. Boiler plate checklists tend to make every patient’s chart read the same. Workaround? – I know how to type. The actual, and helpful, differentiation between my patient encounters is almost always found in my “free text” note. But, not all providers in my office know how to or like to type. When I have to track down another provider to find out the information I need, there are now two of us not seeing patients.

Safeguarding patient privacy in an EMR is more complex. Sensitive results or comments are sometomes consciously avoided in the EMR or are deeply buried underneath a number of more clicks, scrolls, and screens. Workaround? – See above about physically tracking down another provider or more likely, that valuable information is not available in the medical record at the time that you need it. The route(s) of clinical information coming in from outside our office like lab results, X-ray readings, and specialists’ consultations are multiple, varied , and often obscure in our EMR. The vigilance required to NOT miss such reports is INCREASED, not decreased, in EMR. Workaround? – I ask the nurse, medical assistant, or front desk staff to track down the information by telephone or fax just like “in the old days.”

Correction of recorded errors like dates, or names, or even diagnosis can be tedious in the EMR.  A simple single line cross-out and rewrite did it in the paper record. The EMR requires multiple cursor clicks and several screens to do the same. The timing of the clicks, or more nearly correct, the sequence of clicks can be important for success. Workaround? – Sometimes I will delete a whole section of generic computer-speak in an EMR section because I can’t easily change one or two lines  (2 screen colors, at least 3 clicks, and a small check box way down at the bottom of the screen are often involvedin making an EMR correction).

The EMR has reduced the delegation of accepted clinical tasks. Renewing or initially writing common prescriptions ordered by me is not permitted to be done by the nurse practitioners or nurses on our EMR. Instead of a verbal request to a trusted professional, my time and attention is required on at least three computer screens, up to half a dozen clicks, and my entry of my unique password to do that. True, the prescription is sent electronically to the correct (usually) pharmacy, but the nurse or office staff used to do that quite quickly via fax, and it took less of my time. Work around? – Perhaps patient safety clearly trumps convenience here, so I have not spent much time thinking about a work around for this, but it does continue to disrupt a previously smooth work flow.

My computer keyboard is in one room, and I use three other rooms as exam rooms, To complete a note, look up a growth chart,  check results, answer an unexpected question from a parent, or order a medication I often do a far amount of time-consuming walking back and forth between rooms. Workaround? – Why not just get a tablet?, you ask. Well for some mysterious reasons neither of our EMRs support that functionality in our office. After several frustration attempts we know that the tablet works beautifully at IT headquarters, but  not in our office.

What benefits most from EMR in the office setting?
Reimbursement and research.
Clinically the only useful information to know about an ear infection is whether it is “left” or “right”. Our EMR requires a half dozen more adjectives before the diagnosis is “recorded”. It has no effect on reimbursement now (what we are paid for that office visit) ,as far as I know, and I can only hope that such minutiae won’t affect reimbursement in the future.
There are also half a dozen adjectives required to record the diagnosis of “nose bleed”, and I can only imagine that somewhere out there exists a researcher just waiting to write the definitive article on “recurrent, non-injury, chronic, episodic nosebleed” which happen more often on the “right” than the “left”.

Both these R&R benefits of EMRs are quite removed from improving actual clinical care. That is another reason for my move to “the dark side”, and this current blog that deviates from my founding pledge to NOT publish personal rants.

If you chose to dismiss this particular rant as “just another doctor complaining about his poor lot in life”, you should read a more scholarly short treatise on the same subject: “Accelerating Innovation in Health IT”,  New England Journal O f Medicine, 375:9, September 1, 2016, 815-7 (1).

 


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