Michael Jackson

Michael Jackon’s demise is a classic story of medical mismanagment – he was done-in by a fragmented healthcare system which is too focused on financial gain. The fact that Mr. Jackson was able to obtain prescriptions for anesthetic agents, not just pain medications, from multiple doctors is truly astounding. While it is becoming painfully clear that Michael Jackson was “playing” the healthcare system to feed his addition, it is even more painfully true that he was allowed to do so to the point of his own demise. Possibly with a physician standing at his side? It should be made absolutely clear that administering some of these agents, particularly propofol, in a non-critical care or operating room environment without physiciological monitoring is extremely risky and shows careless disregard for the sanctity of life. How did this happen? This man was obviously crying out for help and the last thing he needed was another prescription for pain medications or anesthetic agents.

Where was the CARE in his healthcare?
Would a siloed EMR in a doctor’s office have changed the course of this man’s medical treatment?
Did any of his doctors ever communicate with any other doctor caring for this patient?
Did the malpractice system prevent this death – does it really improve healthcare quality or just add to cost of healthcare?
Will a malpractice lawsuit against a physician implicated in the care of Mr. Jackson prevent this from happening again?
Is the healthcare REFORM process going to lead to changes that prevent this type of healthcare from happening in the future?

Do not believe for a second that this is an isolated problem – as a physician I see this type of patient often. The quality of care issue is deep and complex – but without addressing this problem simply covering more lives or further regulating the insurance industry is not going to solve the prime problem.

Healthcare over-expenditures are the result of a system that does not reward good care, rewards overuse of procedures and diagnostic testing and has pitted every major stakeholder against each other resulting in increasing fragmentation and intermediation. The problem is that the healthcare system is NOT a SYSTEM. Address this problem and I believe that all of the other issues fall in place. Healthcare REFORM that does not address this problem will not reduce cost of care nor improve quality of care. It will just further ration resources already made overly scarce by malalignment of interests and misappropriation.

Doctors Are Killing Their Profession, the Healthcare System and Their Patients with Paternalism.

Paternalism is inculcated in physicians minds through training and work culture in this country. It is the most critical problem underlying the healthcare crisis. Until we eradicate paternalistic behavior and form balanced, collaborative relationships with our patients, no federal or state regulations will be effective in improving quality or reducing costs. It takes two to do healthcare, and it takes mutual respect and recognition of the patient as a partner to do it right. But that will not be easy.

Every day, medical schools indoctrinate upcoming doctors with paternalistic behaviors. Your patients dont want to know the details, they want to get well, its your responsibility to make them well. You, doctor, should shoulder the responsibility.

I experienced the results of this behavior personally. When my wife and I were consulting with her oncologist, the director of one of the largest oncology hospitals in our area, my wife asked why she felt so much more drained after the last round of chemo. I said, half jokingly, that they wanted to push the dose as far as you could possibly take, not knowing that, in fact, they had done just that. The oncologist turned to me and smiled and said, exactly and then exchanged smiles with two of his fellows in the room. My wife turned to him and said, it would have been nice if you had told me that was coming. No doubt the oncologist was trying to salvage a bad situation, my wife was stage IV by this time. But none-the-less, the result was we trusted this doctor less.

Society has evolved. Paternalistic behavior is no longer acceptable, if it ever was appropriate. It must be eradicated.

What is paternalism? Paternalism can be defined as; A means of patient management in which the physician assumes ultimate authority for the patients welfare in such areas as healthcare decisions, following physician orders, knowledge of treatment options, access to medical records including study results. The term is also pejorative in the sense that management assumes inferior status for patients. (Re-worded from a definition found in Ask.com)

There are numerous forces that reinforce paternalism in the doctors world. First and foremost, is the philosophy of medical malpractice risk management. Doctors are told to take complete responsibility for every order they give a patient. If you give an order, doctor, you better make sure there is some way to track that order and make sure that the patient follows through. If it was important enough to order, then it is important enough to make sure the order is done and you receive the result.

The underlying belief that the doctor is responsible for the patients behavior is erroneous. The doctor is responsible for making sure the patient hears and knows that the order should be done. Period.

At this point, some would argue that the patient does not know what the doctor knows. The doctor is the professional trained to know the importance of a screening colonoscopy, for example. The malpractice profession would probably put it this way, in court; Did you follow-up with the patient to make sure the patient had the routine colonoscopy you recommended, Doctor? Why not Doctor? If you had done your job, the patients colon cancer probably would have been diagnosed in time for a cure, Doctor. Now its too late. In fact, these re-enactments are actually performed for doctors at risk management meetings by malpractice defense attorneys on behalf of malpractice insurance companies to comply with state regulations. Yes, even the government promotes paternalism.

At the September, 2009 Medicine 2.0 meeting in Toronto, E-patient Dave Debronkart a member of the Society for Participatory medicine quoted Dr. Stanley Feld who offered a different approach: The Patient is the player, the Doctor is the coach. This is what patients want, too. Health 2.0 and Medicine 2.0 are premised on this concept. Patient participants in these meetings are usually not medical professionals. They, by and large, abhor paternalistic behavior. They want their medical data, they want to learn about their medical problems, diagnostic and treatment options from their doctors. They want their questions answered. But, they want to make their own informed decisions. So do I.

Many patients, however, even those who say otherwise until they are very ill, promote paternalism too. For example, many patients say to me; Doctor, I will do whatever surgery you recommend. Just dont tell me the details. This is much more common than most advocates of patient-empowered medicine would want to believe. However, this is not a reason to abandon the tenets of participatory medicine. In fact, when a patient expresses a desire for paternalistic behavior on the part of the physician, it is up to the physician to persist in offering all possible treatment options, not just the easiest to perform or the most profitable.

Dave put it this way. He said that a while back he decided to take singing lessons. He said he never practiced in between lessons and after a year and a half, he was not better than when he had started. It wasnt my vocal teachers fault, it was mine.

Freedom of information exchange between doctors and patients is the first step to eradicating paternalistic behavior. But even here there are obstacles, mostly from the very industry that benefits indirectly from paternalistic behavior, the malpractice industry. This is the primary reason the malpractice industry needs to be better regulatedbecause this will improve the doctor-patient relationship and result in better health. Reducing the costs of defensive medicine and malpractice insurance, while desirable, are less important for patient health.

I have a friend whose child was born with a serious medical condition that required a prolonged stay after birth. After the child was discharged and it was time to begin outpatient care with a local pediatrician, my friend could not obtain the medical records from the hospital. The hospital is a large, well-known, highly respected institution. Nonetheless, it took months for the pediatrician to obtain the medical records. The reason most often sited by my colleagues for not giving free access to medical records is medical liability. In fact, it was this event that caused us to be friends together in the first place, and to work together on a comprehensive Internet healthcare system platform.

Fixing the healthcare system in this country requires enactment of federal legislation that requires that a healthcare provider or institution to provide medical records within a reasonable period of time at a reasonable cost. HIPAA did the opposite and it is often used as an excuse to NOT provide patients with information about their care.

Healthcare reform must open the process to the patient, provide the patient with study results at the same time they are delivered to the doctor, empower the patient with tools (like the DocPatientNetwork) for asking their doctors about the meaning of lab results or for discussing problems online. Just as important, this technology must document that the patient received and read the order. It would be helpful if the software provided reminders as long as the software vender does not assume responsibility for the patients behavior. Doctations technology supports collaboration between doctors and patients. Health reform must remove obstacles.

The argument about which takes primacyphysician beneficence or patient autonomyis over. It is now clear that the right of the patient to act autonomously always outweighs obligations of beneficence toward the autonomous patient. (Ask.com definition of paternalism) The path to better healthcare starts here.

E-Patient Dave said it this way at the Medicine 2.0 conference: Gimme my Damn Data!

Things are not always as they seem

Healthcare reform is a hot topic. Everyone from the President to the US Congress to the guy who cuts the grass is conscious of the national debate. Paradoxically, however, it never ceases to amaze that in our information society, in which any topic can be researched to the satisfaction of any level of curiosity-there exists such confusion.

Perhaps the overwhelming volume of facts, opinion, spin and political rhetoric has converted our culture to that of Headline Readers-those who take snippets, sound bytes and 128 character thoughts, formulate a position and stick to this cursory survey with the tenacity of white on rice. Some even resorting to T shirts and bumper stickers.

An interesting corollary to this is that when something sounds like a good idea, common sense-perception does take shape in reality. The current reality is, as you read this, costing you money. Such a situation is occurring in the EMR/PHR/Interoperability world of Patient-Centric Healthcare.

Do not misunderstand. I am an ardent supporter of this technological evolution and I personally believe that for the United States to not have universal health coverage is our national disgrace. I just think that were going about it the wrong way!

This is one mans opinion so allow me to explain.

Interoperability of existing systems, touted as a goal of this transition, wont work. The 25 cent explanation is that getting Patient records, the scheduling system and the billing system to work in harmony is like getting a group of people speaking different languages to communicate. Its not. Its like getting a bunch of people and animals speaking different languages, of different intelligence, different ages, cultures etc to interact in a functional manner. You could do it but it will operate at the level of the LEAST capable, the LEAST efficiency, sacrificing power and capability from all but the weakest link. It will not work and is not worth the effort.

A new, networked system built from the ground up is the only way to go. Period. End. To my original point, when even an interested, educated person sees a TV ad stating that Patient records dont talk to billing, dont talk to labs-thats what Im working on- they should realize that even though it seems logical, it is, in fact, not. It degrades the capabilities of the strongest components to salvage the utility of the weakest. It is against progress, natural selection and innovation. Furthermore, in healthcare, it does nothing to improve the lives of Patients or their Doctors.

Conversely, Patient-centric care does work toward that objective. It focuses on fulfilling the Patients need to maximize the Doctor-Patient relationship. It means that the information used in promoting the health of the Patient is complete, Transparent and communicated between Patients and all involved healthcare personnel. It involves Patient responsibility to communicate inaccuracies and Doctor responsibility to communicate with colleagues to maximize the team approach to benefit the Patient. It is the spirit of meaningful use of Health Information Technology.

There seems to be agreement that if Patient hospital records are made available to their Doctors in a common repository these goals can be achieved. New York has initiated such a multi-million dollar program. Again, a well intentioned concept falling short of any real benefit.

Ninety percent of healthcare occurs in a Doctors office or clinic-not the hospital. More and more care, in fact, is being purposefully shifted out of the inpatient setting and to the outpatient. Every discharge from every hospital, ER, ASU or urgent care facility MUST include a follow-up plan. Additionally, Patients history in the hospital is based entirely on the Patients recollection. There are always inconsistencies, for example, in the past surgical history even if the surgery took place in that institution! Medication reconciliation, aimed at avoiding dangerous interactions and redundancy is done by asking the patient which medications they take and having the Admitting Physician sign a form attesting to the completeness and veracity of that list-even if they didnt prescribe them. Then they are asked to which should be continued or discontinued upon discharge.

Furthermore, lets assume that the records are complete. When does the Patient get to review them? To correct inaccuracies? They dont. In fact, at the follow-up, what is the mechanism used by the Doctor to view them? How does it fit into the office flow? What if a Patient has never been hospitalized? What if their medical records are on paper or a siloed EMR? The road to ruin is paved with good intentions.

This logic stream is not meant to be contrary for contrarys sake-it is meant to point out the issues with an overly simplistic solution to a culturally ingrained and complex situation.and to offer a solution.

The DocPatient Network, featuring Doctations is the solution. It is an integrated complete cloud computing solution for the ambulatory healthcare setting. It encompasses all functions from scheduling and billing, EMR, PHR through the integrated iMedicalHome patient component populated by data generated from the Doctor-Patient encounter. It converts the encounter into currency that automates ALL office functions. Hardware required is an internet connection and a computer with a standard browser. The most expensive subscription costs $2200/year, the least $35/month.

It is the difference between each Doctor, hospital etc maintaining a chart for each Patient versus each Patient having their own chart to which each of their providers contribute.

For data sharing, the dMR has the unique Shared Patient Data Base in which every Patients past history (past medical history, past surgical history, allergies. Medications etc) is integrated and entered ONCE (and sent to the Patient as their medical profile for their approval) rather than requiring the Doctor to research the Patients hospital chart. This history is integrated and appears once an encounter is begun at an office visit.

In fact, a Patient need only register data (insurance, address, birthdate) at one DocPatient network office. At subsequent provider offices they need only sign in. No more forms-less waiting time-more accurate information.

The Doctors chart gets smarter as the Patients other providers update the SPDB. Paperwork is minimized as documentation is maximized, saving time better spent with the Patient, not accessing a website to wade through an entire hospital record.

The Patient gets more quality time and information from the Doctor as well as a free HER/PHR/Medical Passport and ability to communicate online with the Doctors staff.

Why would any Doctor not want to give this to their Patients?