Daily Healthy: medication

Quick Medicine quickly explain to your customer

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By the time the next decade rolls in there will be no paper charts. There will probably still be paper floating around in various capacities, but there will be no one charting on paper. The term “charting” itself may become obsolete, like yonder or popinjay. The term EHR, which is what replaces the paper chart, won’t last either because it doesn’t roll easily off the tongue like say, email instead of letter or missive. EHRs don’t do anything else easily, so chances are EHRs themselves won’t last much longer, relatively speaking. Sooner or later, the national spotlight will shift to something other than health care, and other electronic critters will emerge from the shadows.  What will they be? What should they be? Those could be two very different answers. 
<h4>
What Should Be</h4>
Have you noticed how people advocating for EHRs use the word quickly in practically every sentence? Mega EHR allows you to quickly document XYZ, and Super EHR can quickly gather all historical data and display it in a summary dashboard which allows you to quickly assess the status of the patient. You can quickly send prescriptions to pharmacies, quickly order a bunch of tests, and quickly print out (the horror!) education materials. Your staff can quickly schedule patients, quickly answer questions, quickly verify eligibility and quickly drop claims. Your patients can quickly get answers, quickly schedule visits and quickly have their concerns resolved. 
 
Of course, most of these things are aspirational at this point, but the language is indicative of the thought process behind EHR design: hurry up and get it over with. Time is money and quickly disposing of each patient is absolutely imperative in a high functioning health system. You could argue that there is nothing wrong with speeding up, or even eliminating, administrative tasks, and you would be right. But is reviewing historical information on a patient and documenting today’s encounter an administrative task? When reviewing histories is compressed into briefly glancing at a bunch of <a href="http://en.wikipedia.org/wiki/Sparkline" target="_blank">sparklines</a> like they have for the stock market, it may seem like you are engaging in an administrative task. Buried somewhere deep in the dark chart though, there may be a note you made about Mary’s difficulties to navigate the front porch stairs last year. 
 
Why did you make that old note? It’s not required for billing. It’s not demanded by insurers. What made you type that in? Do you usually make notes about irrelevant things that you fully expect to never see again? When you used paper charts, you had to flip through many pages to gather the information you can now quickly glean from your infographic patient dashboard. And while you were paging back and forth through that chart, chances are you would have stumbled upon that little note that seemed important enough for you to scribble down last year. And maybe you would discover other little notes too. 
 
Is reading a book the same as reading the <a href="http://nfs.sparknotes.com/macbeth/characters.html" target="_blank">SparkNotes</a>? Oh, you will pass the test either way, and may even get better scores with the SparkNotes version, but is it the same? Is reading this: “Ultimately, he is unable to bear the psychic consequences of his atrocities”, the same as reading this: “Tomorrow, and tomorrow, and tomorrow, /Creeps in this petty pace from day to day, /To the last syllable of recorded time; /And all our yesterdays have lighted fools /The way to dusty death. Out, out, brief candle! /Life's but a walking shadow, a poor player, /That struts and frets his hour upon the stage, /And then is heard no more. It is a tale /Told by an idiot, full of sound and fury, /Signifying nothing.”? Which version leaves you better equipped to address the story at hand, and the story-teller himself as a whole person? And which version makes you, the reader, feel more like a whole person? 
 
Whatever else the EHR of the future might do, it should quit trying to quantify, summarize, highlight and decontextualize the soul out of the medical record. Disposing of patients quickly should not be our goal. Other than being demeaning and dehumanizing for all involved, seeing patients quickly is the root of all our health care woes. In an environment increasingly hostile to human interaction, EHRs should ferociously fight to create more time for patients to spend with their doctors. EHRs should automate the business of medicine and eventually the science of medicine, while protecting the art of medicine. And by art, I don’t mean compassion and advocacy. I mean the application of professional judgment, without which the science is incomplete and will always be incomplete, regardless of how many genes we can map or how many bots we can implant in ourselves. 
 
Assuming that the business of health care will be marching along the glorious path currently laid out by our betters, the EHR of the future should endeavor to become a silent background processing machine. Natural language processing should be the first and foremost feature to be implemented to perfection. The EHR should parse and extract useful information from doctor-patient interactions to maximize physician reimbursement by maximizing claim values (yep, I just said that), and by scouring all opportunities to obtain incentives and bonuses from the overlords, and automatically applying for all, without user intervention. Not an easy task, but IBM Watson could drop out of medical school and take this on. 
 
The flip side of maximizing revenue is to cut overhead. No practice needs a scheduler. Let patients schedule themselves online or on the phone. Let them check in and let them room themselves (think about those little restaurant gizmos that beep when your table is ready). Let them take their own vitals and answer all those preliminary questions on their own. For the outliers, the frail and the elderly, one medical assistant can cover these tasks for bigger practices. It doesn’t sound much like an EHR because it isn’t. 
 
What else costs money, but has practically nothing to do with medicine? All the school notes, the back to work notes, the disability forms, trade forms and all other forms, authorizations, pre-authorizations, eligibility checks, statements and everything in between, can be delegated to computerized self-service. Get the medical records online and let patients have at it. Make it user friendly like all other trivial consumer facing apps that have absolutely no bearing on enterprise technologies. Make them colorful and fun. Show pictures, animations and ads. Put them on the iPhone. Monetize the heck out of everything, and remove this purely administrative burden from the practice. 
 
And then comes a moment when restraint needs to be religiously exercised. Stay the heck away from the exam room. Let people say whatever they want to say. Let doctors ask whatever they want to ask. Forget about boxes, no matter how useful they look. Forget about structure too, because Watson will be taking care of that. Don’t make documentation easy, because taking notes is not just about documentation. It is mostly about the background thought process that makes one decide what to note and what to discard. Remember, the way you would use different styles of handwriting and text of different sizes or boldness, and how you added critical notes in the margins, or big pointy arrows? Actively taking notes helps you synthesize information, internalize, memorize and understand the narrative (programmers, think back to your college days). 
 
If EHRs want to be helpful, let them be secretaries. Arrange the notes in a way conducive to better information retrieval. Don’t summarize and don’t impose your (or your machine’s) notions of what is or is not important. Collate and bind everything into a patient book. Remember that this is a reference book and the user can read at a 30th grade level. It is not a cookbook and it is certainly not a picture book. Add a table of contents. Use the computer to make it dynamic. Make it easy to flip pages in an electronic context. Make the fonts nice and large, and do learn from beautifully maintained old paper charts. Go out and look at some before they are extinct. You can’t improve that which you don’t know. 
<h4>
What Will Be</h4>
Of course none of the above is going to materialize in a meaningful way, except maybe the infantilized consumer facing EHR. Health care is going retail and health care will care about its customers precisely as much as Walmart and Amazon do. And health care will care for its employees as much as Walmart and Amazon do. When providers are all transitioned to having their employer paid for value, EHRs will become very easy to use. A few big buttons, at the bottom of pages prefilled with stereotypes and sprinkled with colored sparklines, should quickly do the job (i.e. Order, Refer, or Deny). There will be nothing for you to document and nothing for the patient to convey because the system already knows everything there is to know. Eventually, it will dispense with the buttons altogether, and your job will be to quickly explain to your customer why the system did what it did. And you will never have to use a computer ever again. Mission quickly accomplished.</div>

health care Medical medication Quick Medicine quickly explain to your customer

By the time the next decade rolls in there will be no paper charts. There will probably still be paper floating around in various capacit...

How Psychotherapy Changes the Brain

3:03 AM Meme Art Studio 0 Comment

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By <a href="http://www.psychiatry.org/mental-health/healthy-minds-blog-contributors" target="_blank">Serina Deen, MDMPH</a><o:p></o:p> 
 
 
 
When I first see patients for evaluation, they often tell me that they’ve debated starting a “biological” treatment such as medication, versus a “psychological” treatment such as psychotherapy. I’m happy to report that as brain imaging technology advances, we’re finding that this distinction may be obsolete.  <o:p></o:p> 
 
 
 
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Psychotherapy is also “biological” in that it can lead to real functional and structural changes in the brain.   In fact, sometimes <a href="http://www.psychiatry.org/File%20Library/Mental%20IIlness/Lets%20Talk%20Facts/APA_Psycotherapy.pdf" target="_blank">psychotherapy </a>and <a href="http://apahealthyminds.blogspot.com/2011/01/six-tips-for-talking-to-your-doctor.html" target="_blank">medication </a>produce surprisingly similar changes in the brain.  We still have a lot to learn about the topic, but below are some examples of what researchers have been finding so far.<o:p></o:p></div>
 
Functional Changes in the Brain:<o:p></o:p> 
 
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEisEmTMLfCdT4Vlws_S4zzD_DZMXoQasORIMPkNr9_AAZYC16pulHHwZa4jpsQNym3xQa3OrnQCf-4ulTtpnf-Fj9qhDljjpq41XkVv3PwdWVE2WuneH9ceuzl0iAN3JZ-X31uarvGAS8oU/s1600/Deen+pic+1.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="How Psychotherapy Changes the Brain" border="0" height="130" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEisEmTMLfCdT4Vlws_S4zzD_DZMXoQasORIMPkNr9_AAZYC16pulHHwZa4jpsQNym3xQa3OrnQCf-4ulTtpnf-Fj9qhDljjpq41XkVv3PwdWVE2WuneH9ceuzl0iAN3JZ-X31uarvGAS8oU/s1600/Deen+pic+1.jpg" title="How Psychotherapy Changes the Brain" width="200" /></a>In one study, researchers at UCLA found that people who suffered from depression had abnormally high activity in an area of the brain called the prefrontal cortex.  Those who got better after they were treated with a type of therapy called interpersonal therapy (IPT) showed a decrease in activity in the prefrontal cortex after treatment.  In other words, IPT seemed to “normalize” brain activity in this hyperactive region. 
 
 
 
Another study looked at people who have <a href="http://www.psychiatry.org/obsessive-compulsive-disorder" target="_blank">obsessive compulsive disorder</a> (OCD), who tend to have an overactive area of the brain called the caudate nucleus.  Treatment with a type of therapy called cognitive behavior therapy (CBT) was associated with a decrease in the hyperactivity of the caudate nucleus, and the effect was most evident in people who had a good response to CBT.  In other words, the better the therapy seemed to work, the more the brain activity changed. 
 
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Changes in Brain Volume:</div>
 
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People with chronic fatigue syndrome (CFS) suffer from debilitating fatigue.  People with CFS tend to have a decrease in a type of brain tissue called grey matter in the prefrontal cortex of the brain.  Researchers in the Netherlands gave people with CFS 16 sessions of CBT, and found significant increases in gray matter volume in the prefrontal cortex.  This seems to suggest that the CFS patients were able to “recover” some gray matter volume after CBT.</div>
 
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Similarities and Differences to Medications</div>
 
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<a href="http://www.psychiatry.org/File%20Library/Mental%20IIlness/Lets%20Talk%20Facts/APA_Psycotherapy.pdf" target="_blank">Psychotherapy </a>sometimes seems to work in similar ways as <a href="http://apahealthyminds.blogspot.com/2011/01/six-tips-for-talking-to-your-doctor.html" target="_blank">medications</a>, and other times appears to have different mechanisms of action.</div>
 
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In the study mentioned previously about people with <a href="http://www.psychiatry.org/mental-health/depression" target="_blank">depression,</a> both IPT and the antidepressant paroxetine (Paxil) showed a decrease in prefrontal cortex activity.  And with OCD patients, both CBT and the antidepressant fluoxetine (Prozac) produced similar decreases in activity in the caudate nucleus.  </div>
 
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However in a different study, the antidepressant Venlafaxine (Effexor) produced changes in different parts of the brain than IPT in depressed patients.  This shows that there is variability in how different treatments work in the brain.</div>
 
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How Psychotherapy Produces Brain Change</div>
 
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We now know that the brain keeps changing, even after we become adults.  Learning leads to the production of new proteins, which in turn can change connectivity in our brains in a process called neuroplasticity.   Indeed, researchers in Germany showed that certain neurochemicals involved in neuroplasticity increased in depressed patients who got better after a course of interpersonal therapy.  </div>
 
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Picking a Treatment that Works Best for You Even though we know that both <a href="http://apahealthyminds.blogspot.com/2011/01/six-tips-for-talking-to-your-doctor.html" target="_blank">medication</a> and <a href="http://www.psychiatry.org/File%20Library/Mental%20IIlness/Lets%20Talk%20Facts/APA_Psycotherapy.pdf" target="_blank">psychotherapy</a> can change our brain, we still have a long way to go in learning exactly how that happens and when to use what treatment. Given a specific mental illness, sometimes medications work best, sometimes psychotherapies are the best option, and sometimes it’s a combination of the two. In addition, there are different types of psychotherapies that work for different illnesses, just as there are many different types of medications.  If you’re considering seeking help for mental illness, it would be helpful to talk with a trained professional about what would work best for you.  <o:p></o:p> Read tips on what to expect during your <a href="http://apahealthyminds.blogspot.com/2013/03/what-to-expect-for-your-first-visit_21.html" target="_blank">first visit with a psychiatrist</a>   </div>
 
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"Let's Talk Facts" brochure on <a href="http://www.psychiatry.org/File%20Library/Mental%20IIlness/Lets%20Talk%20Facts/APA_Psycotherapy.pdf" target="_blank">Psychotherapy</a></div>
 
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<a href="http://www.nimh.nih.gov/about/director/2014/brain-awareness.shtml?utm_source=govdelivery&utm_medium=email&utm_campaign=govdelivery" target="_blank">Brain Awareness blog</a> post from NIMH Director Tom Insel, MD </div>
 
 
 
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APA Releases <a href="http://apahealthyminds.blogspot.com/2013/11/apa-releases-list-of-five-uses-of.html">List of Five Uses of Psychiatric Medication</a> to Question<o:p></o:p></div>
 
 
 
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Six tips for talking to your doctor about <a href="http://apahealthyminds.blogspot.com/2011/01/six-tips-for-talking-to-your-doctor.html">medication</a><o:p></o:p></div>
 
 
 
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For more information about <a href="http://www.apa.org/helpcenter/understanding-psychotherapy.aspx">psychotherapy</a><o:p></o:p></div>
 
 
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<a class="twitter-share-button" data-count="horizontal" data-related="APAPsychiatric" data-via="APAHealthyMinds" href="http://twitter.com/share" style="text-align: center;">Tweet</a></div>
 
 
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depression medication OCD psychiatrist psychotherapy How Psychotherapy Changes the Brain

By Serina Deen, MDMPH When I first see patients for evaluation, they often tell me that they’ve debated starting a “biological” treatme...

The Bionic Medicine of Programmable People

11:28 PM Meme Art Studio 0 Comment

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A couple of weeks ago I wrote <a href="http://onhealthtech.blogspot.com/2012/08/curb-your-enthusiasm.html" target="_blank">a post</a> about the clueless, but endearing, enthusiasm of technology people as applied to solving the health care problem. A few days ago Dr. Davis Liu published a post on <a href="http://thehealthcareblog.com/blog/2012/08/31/vinod-khosla-technology-will-replace-80-percent-of-docs/" target="_blank">The Health Care Blog</a> describing the vision of <a href="http://techcrunch.com/2012/01/10/doctors-or-algorithms/" target="_blank">Vinod Khosla</a>, the famed venture capital maven, of replacing doctors with machines. It turns out that Mr. Khosla wrote a series of <a href="http://techcrunch.com/2012/01/09/khosla-artificial-intelligence/" target="_blank">three</a> articles at the beginning of the year in a technology publication describing how his pioneering vision will replace people in industries where either he or his <a href="http://techcrunch.com/2012/01/15/teachers-or-algorithms/" target="_blank">wife</a> are investing capital. Venture capitalists (VCs), although I’m sure they wouldn’t agree with this assessment, are a combination of professional gamblers and loan sharks. The secret to success is pure luck and ruthlessness, and when the combination works and the ball lands on the exact number on the spinning roulette, venture capitalists make lots of money. This is very different than running a business ala Warren Buffet or even Mitt Romney, let alone inventing a business like Apple or Microsoft. In return for risking funds, venture capital gets its juiciest pound of flesh when the funded business sells itself to the public, hopefully for more than it is really worth, and hopefully for a lot more than the venture capitalist risked. For that to happen, you have to create demand for whatever your fund is investing in at the moment. This is why you find VCs shedding tears at the mere thought of global warming, or telling us that the future is all about “I Robot”, or miraculous genetic “I am Legend” drugs , or “gamification” or whatever happens to make up their current investment portfolio. The problem with letting venture capital dictate humanity’s agenda is that the globe is getting warmer; people are getting poorer, sicker and dumber while a few VCs are getting richer. 
 
So what is Mr. Khosla selling us now? It seems that his machines, outfitted with “bionic” software are set to replace the 80% of “middling” doctors and also 80% of equally “middling” teachers. Only physicians like Dr. House will remain standing (for a short time) so they can be “leveraged” to create even more “bionic” software, and may I suggest that Albus Dumbledore could be used to illustrate the surviving human teachers of the bionic era. If you are a little bit familiar with the startup world, then you probably know that a business based on services provided by people is not an appealing investment gamble, because it doesn’t scale well, i.e. revenues and EBIDTA cannot go simultaneously through the roof at the same incendiary rate, because people need to be paid for labor. The trick is to find a business model where no labor is required or to find laborers who don’t require payment. A couple of centuries ago we “imported” such laborers from Africa. Today we are “exporting” labor to where those laborers naturally reside. For tomorrow, we are proposing to make machines that work for free. And this in a nutshell is Mr. Khosla’s vision. 
 
Let’s pause for a moment and address the technorati among us. This is not about medical technology for Dr. Leonard McCoy and Dr. Beverly Crusher or about the holographic doctor in Star Trek Voyager, all very awesome and super cool. This is not about stardate 43632.8 or a galaxy far far away. This is about a time frame of “five or ten years” for “bionic” software and “a decade or two” for an army of “Dr. Algorithm” practicing independently. It should be obvious even to the most ardent believers that, in such a short period of time, neither the science of medicine nor technology will be anywhere near the creation of the medical droid that administered to Padme in childbirth. However, these time frames are short enough to appear on corporate financial projections and startup pro-forma budgets. This is about real money and about some flimsy machinery deployed to play doctor to the poor (China and India are mentioned by Mr. Khosla, but the Mississippi Delta can’t be far behind), and if folks are harmed in the process, oh well…. (See below). 
 
Now, how about this “bionic” software that Mr. Khosla envisions to be a temporary bridge between human cognitive endeavor and full machine control in “a decade or two”? Turns out that the term was introduced by a <a href="http://bryce.vc/post/12600078312/bionic-software-and-programable-people" target="_blank">serial entrepreneur</a> in the social media/marketing, hotter than molten lava, sector.  Later adopted by the <a href="http://oatv.com/are.html" target="_blank">O'Reilly AlphaTech Ventures</a> folks who invest in clicks and links and data as well, “bionic” software has something to do with “programmable people” and “it has the potential to unlock a massive amount of unrealized human potential”, presumably as programmed and networked by VC funded programmers. According to <a href="http://topics.wsj.com/person/B/dennis-k-berman/1589" target="_blank">Dennis K. Berman</a>, a WSJ journalist writing about technology and “corporate scandals”, also <a href="http://online.wsj.com/article/SB10001424052970203462304577138961342097348.html#ixzz1ioOP4QRs" target="_blank">cited</a> by Mr. Khosla, we should accept the “rise of the machines” just like we accept earthquakes and hurricanes because it is simply inevitable. And if we still have any doubts regarding the superior intelligence of Jeopardy winning machines, we are reminded that “systems are now of such scale that they can analyze the value of tens of thousands of mortgage-backed securities by picking apart the ongoing, dynamic creditworthiness of tens of millions of individual homeowners. Just such a system has already been built for Wall Street traders”. I am so totally convinced now, but if you need more real life examples, you should read about the $108 million in venture funds going to “bionic” software helping pharmaceutical companies track social media activity to identify doctors more likely to influence their peers, or the $84 million venture investment in “bionic” software to spy on customers and make them buy more fatty food stuff. 
 
According to Mr. Khosla, soon we will advance beyond simplistic “bionic assistance” to “lazy” doctors, and we will no longer be “free to be stupid or political” and “reject” the “cost optimization” served by “Doctor Algorithm” in its medical practice and none of us will need those multitudes of “average” doctors stuck in the “18th century tradition of “first do no harm””. Since VCs are only interested in engineering, as opposed to social engineering, their off the cuff suggestions for the “middling” 80% in any profession or occupation, where wages are proposed to be eliminated from the expenses column, is usually something vapid like “empathy, advice and caring”. Of course “empathy, advice and caring” doesn’t pay anything like actual doctoring, and it is precisely those large wages that need to be eliminated. Highly educated professional workers are also much harder to transform into “programmable people”, like say, the young girls working in one of those infernal laptop assembly lines in China. So once the new troves of captive cheaper-than-machine labor pools have been secured, all that is left in the quest for zero COGS, within the short cash horizons of venture capital, is to eliminate those expensive and volatile knowledge workers from the balance sheet. And since Mr. Khosla’s educated estimate is that “medical diagnosis or 90% of it is an easier task than Jeopardy”, and since he urges us “not to extrapolate the past and what has or has not worked”, it should be easy as pie to imagine a future almost completely free of professional physicians, classroom teachers and non-programmable people in general. 
 
Thus, in Mr. Khosla’s hospital of the future, medicine will be practiced by thinking machines, while floor scrubbing, sheets changing and bed-pan emptying will be left to humans. Eventually, the medical machines, or the few human lords remaining, will probably take on the last yard of efficiency and create menial machines for janitorial purposes, at which point the only human beings in a hospital will be the patients in the beds, and venture capital’s ROI will be inching towards infinity. Unfortunately for Mr. Khosla, or future generations thereof, the transactional volume will be trending to absolute zero, since the “middling” 80%, after advancing to the mindless 80%, are now mostly extinct or have reverted to gathering wild berries where vegetation still remains. I hope being the Supreme Ruler of nothing at all proves to be a very satisfying experience for Khosla Ventures.</div>

health informed consent medication The Bionic Medicine of Programmable People

A couple of weeks ago I wrote a post about the clueless, but endearing, enthusiasm of technology people as applied to solving the health...

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How are you feeling today? Do you feel a bit under the weather? Maybe you have some aches and pains, or a miserable flu, or maybe you have some chronic condition like diabetes or asthma, or some other ailment. Perhaps you could benefit from medical attention, but then again getting medical care is so darn inconvenient and expensive and time consuming, and everybody knows that our health care system is broken, and that health care is full of carelessly infected people, who waited many months just to be pushed around, maimed and exploited by arrogant doctors who never wash their hands, before being packed onto jumbo jets that fall out of the sky on a daily basis. Obviously, something must be done, and soon, or we are all going to crash and burn, or worse, go bankrupt. 
 
Fortunately the uniquely American entrepreneurial spirit of innovation, fueled by unimaginable advances in technology, is finally galvanizing its efforts to fix the American health care tragedy, just like it fixed finance, food, retail, transportation and all sorts of other industries, to our utter delight and immense benefit. It’s also nice to see that in the spirit of global cooperation, our friends across the pond are pitching in with innovative ideas of their own. In the April issue of <a href="http://content.healthaffairs.org/content/32/4/653.full" target="_blank">Health Affairs</a>, two top shelf researchers from England are informing us that a “A Key To Slower Health Spending Growth Worldwide Will Be Unlocking Innovation To Reduce The Labor-Intensity Of Care”. Observing that labor costs are the largest contributing factor to the rising costs of health care, the authors reach the inescapable conclusion that “there is great potential to reduce costs while preserving the quality of care by experimenting with delivery models that require a less costly skill mix”, and they have plenty of examples to support this theory. In Mexico, for instance, people “pay $5 per month to access a health advice hotline before setting foot in a physician’s office” and in India, “assembly line–style eye surgery has dramatically reduced cost without sacrificing quality”. The idea is to utilize technology and innovative labor arrangements to deploy health workers with limited formal training “in a variety of contexts”. “Deployed in low- and middle-income countries to address labor shortages, they could also be used in developed countries to reduce the need for the most highly skilled clinicians”. The main epiphany for me here was that poor countries, with billions of unemployed starving people, can have “labor shortages”!! 
 
But other than that, America is way ahead on this one, and since primary care is, well, primary, it is also the primary place to begin the cutting of “highly skilled clinicians”. The latest buzz comes from <a href="http://takecarehealth.com/what-we-treat.aspx" target="_blank">Walgreens’</a> announcement that its NP staffed retail clinics will now begin diagnosing and treating chronic disease, thus reducing the need for the highest skilled clinicians. The prices are advertised, of course, and look pretty reasonable at between $79 and $122 for an established patient exam, excluding tests, procedures and complicating factors. To illustrate our savings, the Medicare Physician Fee Schedule for an average established patient visit (CPT 99213) is currently $72.81 (national average). For the most complex office visit for an established patient (CPT 99215), Medicare pays doctors $142.90 on average. Convenience is of course priceless, but some caution is necessary because Walgreens may not be willing to “care” for you after all. 
 
In the same issue of <a href="http://content.healthaffairs.org/content/32/4/669.full" target="_blank">Health Affairs</a>, several folks employed by Walgreens are exploring another technology driven, cost-reducing innovation. Using data analytics and health risk assessments ($89 at its retail clinics), Walgreens is introducing the concept of “impactibility modeling” to be layered on top of predictive risk-stratification analytics in order to identify patients who “may not be amenable to the proposed preventive intervention”. So “[a]lthough certain subpopulations are at high risk, they may be denied preventive care because they are not expected to respond to it”. Basically, why spend money on lost causes, “such as people with cognitive or other mental health disabilities and those who have language barriers. Or an organization may exclude all of the very highest-risk patients, because such patients are sometimes regarded as being less amenable than others to preventive care”. Following a convoluted attempt at explaining the ethical aspects of this innovation, the authors recommend that more data should be collected, that “there should be appropriate ethical reviews” and that some pilots be initiated. 
 
Now that we’re pretty much done with primary care doctors and really sick individuals, perhaps we can take our savings up a notch. Health Affairs seems to be a veritable treasure trove of innovation these days, and in its <a href="http://content.healthaffairs.org/content/32/2/385.full" target="_blank">February issue</a>, we find an article from Health Partners in Minnesota reporting $88 savings for each simple episode of care administered by their Virtuwell platform. I have to admit that the logic behind their savings calculations escapes me, but their exquisitely high tech platform is the epitome of labor intensity reduction. You go online, provide a valid credit card number, fill out a bunch of forms answering questions about your condition and medical history (perhaps Barton Schmitt, or something similar), and in 30 minutes or less you receive your diagnosis and plan, from an NP somewhere, including prescriptions and referrals if necessary, for a flat fee of $40. You may call if you must, and you will receive an electronic message in a few days to make sure all is well. This is way better than the Mexican hotline model as far as eliminating skilled jobs, and with some more intelligence injected into the protocols, perhaps a little Watson style analysis, we could probably get rid of the NPs altogether. 
 
A small step in this direction can be found at Walmart, CVS and Safeway, where <a href="https://solohealth.com/products/overview/" target="_blank">SoloHealth</a> is <a href="http://www.amednews.com/article/20130408/business/130409963/7/?utm_source=rss&utm_medium=&utm_campaign=20130408" target="_blank">deploying</a> their health assessment stations which provide “free and convenient access to healthcare”. You can screen your vision, blood pressure, weight, body mass index and as many ads as will fit in 7 minutes or less. All for free. This is not really treatment of disease just yet, but the potential is certainly there. Perhaps you can talk to the Station for 7 minutes, then go shopping, and come back in 30 minutes to get your Virtuwell diagnosis and script, and 30 minutes of shopping, particularly with pediatric patients in tow, could be worth enough to the hosting retailers to be able to share a portion of earnings with the Virtuwell platform owners. Isn’t it amazing how innovations can feed of each other to generate cheaper and more convenient innovations? 
 
If you’re still not convinced, here are a couple more things to consider. First, the fee-for-service issue is automatically resolved by switching health services venues, because retail is one of those more advanced “other industries” and therefore perfectly fine with fee-for-service. Second, everybody wins because retail health care, other than being free and very convenient for shoppers and retailers, has a built in operational feedback loop. You go to a convenience store, load up on soda, Cheetos, Doritos, gummy bears and 50% off holiday candy, screen yourself online, go buy some smokes to alleviate the tension, get diagnosed with diabetes amenable to care, get your prescription filled, and on your way out pick up some of the stuff mentioned on the screening station screen, or recommended for purchase on your patient education handouts, and some beer to go with the smokes and the generic Metformin (it’s not like the machine can tell, right?). Rinse and repeat every three months or sooner if you start experiencing chest pain. They do treat cardiovascular disorders too. And don’t worry; you will get plenty of proactive outreach reminders if you forget your next appointment, from the retailer, the various ad sponsors and your dedicated zero-skills care team. How much more convenient can it get? Problem solved.</div>

health care medication Fast Medicine

How are you feeling today? Do you feel a bit under the weather? Maybe you have some aches and pains, or a miserable flu, or maybe you hav...

You want to do what?!?! The importance of informed consent in treatment

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<div align="center" class="MsoNormal" style="text-align: center;"> </div> <div class="MsoNormal"> By Gail  A. Edelsohn, MD, MSPH<o:p></o:p></div> <div class="MsoNormal"> </div> <div class="MsoNormal"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjHhuvRc7UIvhMRIcBvcdxgA_oN0zE5eApDkZO4EU8KMjylM-Q-jxF5-JvxOpBMJ9VMo4C2MLobcux0BV-KNOu2F9okxMfUOVd1n_gHqs1QqoK_FBO_h_Fmww2IgivNvLI1y7NcBkOWd9X/s1600/informed+consent.jpg" imageanchor="1" style="clear: right; display: inline !important; float: right; font-family: Arial, Helvetica, sans-serif; margin-bottom: 1em; margin-left: 1em; text-align: center;"><img border="0" height="132" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjHhuvRc7UIvhMRIcBvcdxgA_oN0zE5eApDkZO4EU8KMjylM-Q-jxF5-JvxOpBMJ9VMo4C2MLobcux0BV-KNOu2F9okxMfUOVd1n_gHqs1QqoK_FBO_h_Fmww2IgivNvLI1y7NcBkOWd9X/s1600/informed+consent.jpg" width="200" /></a>We come across ads in print, on television and on the Internet for medications and therapies that promise to make your child do his homework without a screaming match, behave better and generally restore harmony to home life. Not so easy, taking a medication raises a host of questions:  How long does the therapy take? Should I as the parent sign off on this? What about the possible serious side effects, such as significant weight gain, thoughts about suicide, risk of diabetes or a life-threatening condition?</div> <o:p></o:p> <div class="MsoNormal"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiv0DIfWlmYXutfyUNRrRoKyogzPi_GXrRhyphenhyphenGXtSpQcAHCz6gtYWPFfLKwIt-R-16dWXylPxUfUTWGb2CSIk6OtTdFqIll9TpVE79xg3mqcP29K18CI4h7dTfzVrVjkV_76NY_XSbcEiSWZ/s1600/African+American+family.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="" border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiv0DIfWlmYXutfyUNRrRoKyogzPi_GXrRhyphenhyphenGXtSpQcAHCz6gtYWPFfLKwIt-R-16dWXylPxUfUTWGb2CSIk6OtTdFqIll9TpVE79xg3mqcP29K18CI4h7dTfzVrVjkV_76NY_XSbcEiSWZ/s1600/African+American+family.jpg" title="" width="134" /></a>Parents and legal guardians make decisions about psychosocial therapy and medication treatment for children and adolescents every day. But who should give permission and sign informed consent?  What should parents, advocates, guardians be looking for or consider before signing informed consent? Is signing a form enough?  What about the child or teen - do they have a voice regarding their own treatment?<o:p></o:p></div> <div class="MsoNormal"> What is Informed Consent?</div> <div class="MsoNormal"> Psychiatric informed consent involves a parent or legal guardian giving permission for his/her child to undergo evaluation and treatment.  It is a process which partly involves receiving sufficient relevant information about the condition, prognosis, risks and benefits of treatment to be given and other types of treatment available. Informed consent is NOT simply a signed and dated form. Parents and guardian should expect informed consent to include<s>:<o:p></o:p></s></div> <div class="MsoListParagraphCxSpFirst" style="text-indent: -0.25in;"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-JeluYpVp8Eur1f6a04-6KMoPSPizt-vsp7J9lMlTgMUHkjEJlmcvIZi0BN7teGNdsuwY1RNe62ffnOcp9qwobl0l-H4l_n-hH4ih89dg68ofujVDgXqOUx4rca62amVGULAdzYDBg5op/s1600/father+&+boy.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="115" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-JeluYpVp8Eur1f6a04-6KMoPSPizt-vsp7J9lMlTgMUHkjEJlmcvIZi0BN7teGNdsuwY1RNe62ffnOcp9qwobl0l-H4l_n-hH4ih89dg68ofujVDgXqOUx4rca62amVGULAdzYDBg5op/s1600/father+&+boy.jpg" width="200" /></a> </div>   The purpose of the treatment <ul> <li>To address a specific condition or diagnosis?</li> </ul> <ul> <li>To lessen symptoms?</li> </ul> <ul> <li> To change behaviors?</li> </ul>   The effects of treatment <ul> <li>How will you know if it is working?</li> </ul> <ul> <li> How long till you see an effect?</li> </ul>   Risks of treatment <ul> <li>Side effects of medications</li> </ul> <ul> <li>Consequences of psychosocial treatment (e.g., therapy can be emotionally difficult)</li> </ul>   Risks of NO treatment <ul> <li>Will symptoms improve over time without treatment?</li> </ul> <ul> <li>Will things get worse or lead to other consequences? (e.g., Untreated individuals are more likely to use substances, get into legal trouble)</li> </ul>   What alternative treatments are available?    For medication <ul> <li>Is it FDA approved for this age and condition? (i.e., prescribed FDA on label)</li> </ul> <ul> <li>If it is prescribed off-label, why?</li> </ul> <ul> <li>Are there any FDA warnings about the medication and what do they mean?</li> </ul> <ul> <li>What is the plan for stopping or phasing out the medication?</li> </ul> <div class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; text-indent: -0.25in;"> <o:p></o:p></div> <div class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; text-indent: -0.25in;"> <o:p></o:p></div> <div class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; text-indent: -0.25in;"> <o:p></o:p></div> <div class="MsoListParagraphCxSpMiddle" style="text-indent: -0.25in;">      Parents and legal guardians are asked to give legal permission or informed consent for treatment.  If a child is in foster care, it may be the parent or it may be child welfare service or court that can give consent.   Where a child is living (home, out of home placement) does not tell you who the legal guardian is.  In some states an adolescent may give informed consent for psychiatric treatment depending on the state’s legislation about mental health procedures. Ideally the parents/guardians and the child should be involved in treatment decision making.</div> <div class="MsoNormal"> Children also have a voice in this process.  Children and youth should be involved in giving assent.  Assent involves providing the child or teen with information about the therapy or medication in terms appropriate to their age and stage of development. The assent process should include opportunities for the child/adolescent to ask questions and have their concerns addressed.<o:p></o:p></div> <div class="MsoNormal"> Gail A. Edelsohn, MD, MSPH, is senior medical officer with Community Care Behavioral Health, clinical professor of psychiatry and human behavior,  Jefferson Medical College, and clinical professor of psychiatry and behavioral science, Temple University School of Medicine.</div>

informed consent medication therapy treatment You want to do what?!?! The importance of informed consent in treatment

By Gail A. Edelsohn, MD, MSPH We come across ads in print, on television and on the Internet for medications and therapies that promise to ...

Effective Addiction Treatments are Available

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<div class="MsoNormal" style="margin: 0in 0in 0pt;"> By John Renner, MD and Frances Levin, MD<o:p></o:p></div> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> We are all saddened by the death of Philip Seymour Hoffman and the many other individuals who have died because of overdoses of heroin or pain medications.  For all of those individuals who struggle with opioid use problems, it is important to realize that help is available and that effective treatment can restore them to productive lives.  Some 4.7 million people in the U.S. have used heroin at least once in their lives.  It is estimated that nearly a quarter of people that use heroin become dependent on it. Whether it be through mutual support programs such as NA, long-term residential treatment, or addiction pharmacotherapy with buprenorphine, methadone or ER naltrexone, no individual need fear that their condition cannot be treated.  Friends and family members also need to be educated in the use of intra-nasal naloxone for the reversal of opioid overdoses.   APA has long fostered the development of addiction focused training <a href="http://www.psychiatry.org/practice/professional-interests/addiction-psychiatry">programs for psychiatrists</a>.  Many psychiatrists have been specifically trained to provide office-based addiction pharmacotherapy and to manage the co-occurring psychiatric disorders that often complicate recovery from substance use disorders.  <o:p></o:p></div> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> More information:<o:p></o:p></div> ·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">         Information on <a href="http://www.psychiatry.org/addiction">addiction</a> ·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">         <a href="http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA13-4742" target="_blank">Opioid Overdose Prevention Toolkit</a> (SAMHSA)<o:p></o:p> <o:p></o:p>·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">         <a href="http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx">Substance use treatment locator</a> (SAMHSA)<o:p></o:p> ·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">         <a href="http://buprenorphine.samhsa.gov/bwns_locator/">Buprenorphine Physician and Treatment locator</a> (SAMHSA)<o:p></o:p> ·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">         For psychiatrists:  <a href="http://pcssmat.org/">Providers Clinical Support System for Medication Assisted Treatment</a><o:p></o:p> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> Blog contributors:<o:p></o:p></div> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> <a href="http://2.bp.blogspot.com/-Ofo4edMWxtY/UvFcrabrxHI/AAAAAAAAAyc/eubxcdyVte4/s1600/renner2.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="170" src="http://2.bp.blogspot.com/-Ofo4edMWxtY/UvFcrabrxHI/AAAAAAAAAyc/eubxcdyVte4/s1600/renner2.jpg" width="135" /></a>John Renner, MD<o:p></o:p></div> Member, APA Council on Addicition Psychiatry (Past Chair) Director of Addiction Fellowship Program,<o:p></o:p> Professor of Psychiatry,  Boston University School of Medicine<o:p></o:p> Associate Chief of Psychiatry, VA Boston Healthcare System<o:p></o:p> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> <a href="http://2.bp.blogspot.com/-HVSelmRz3os/UvFchsGxd-I/AAAAAAAAAyU/Vp6bWczaW7Y/s1600/levin.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="145" src="http://2.bp.blogspot.com/-HVSelmRz3os/UvFchsGxd-I/AAAAAAAAAyU/Vp6bWczaW7Y/s1600/levin.jpg" width="135" /></a><span style="color: black; font-family: "Calibri","sans-serif"; letter-spacing: 0.2pt; mso-ascii-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; mso-hansi-theme-font: minor-latin; mso-themecolor: text1;"></div> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> </div> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> </div> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> <span style="color: black; font-family: "Calibri","sans-serif"; letter-spacing: 0.2pt; mso-ascii-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; mso-hansi-theme-font: minor-latin; mso-themecolor: text1;"> Frances Levin, MD</div> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> <div class="MsoNormal"> Chair, APA Council on Addiction Psychiatry Kennedy-Leavy Professor of Psychiatry, Columbia University Medical Center Director, Addiction Psychiatry Fellowship, New York Presbyterian Hospital New York State Psychiatric Institute</div> <div class="MsoNormal"> </div> <span style="color: black; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin; mso-themecolor: text1;"><o:p></o:p> </div> <a class="twitter-share-button" data-count="horizontal" data-related="APAPsychiatric" data-via="APAHealthyMinds" href="http://twitter.com/share">Tweet</a><script src="http://platform.twitter.com/widgets.js" type="text/javascript"> </script>

Effective Addiction Treatments are Available

addiction medication overdose Phillip Seymour Hoffman psychiatrist training substance abuse treatment Effective Addiction Treatments are Available

B y John Renner, MD and Frances Levin, MD We are all saddened by the death of Philip Seymour Hoffman and the many other individuals who have...

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