On Friday, Eric Shinseki, the Secretary of the Department of Veteran Affairs, arrived at the White House, and when he left 45 minutes later he was no longer employed.

This resignation comes after weeks of controversy and outrage around underperformance and coverups at the Veteran Health Administration. The New York Times has a good infographic on the panoply of issues which include data falsification, marathon wait times even for urgent medical issues, coverups, and manipulation of care to artificially improve indicators.

Shinseki's resignation may imply that the problems at the VA derive from this administration or even this individual. Unfortunately, that's far from the truth. As Jon Stewart insightfully detailed recently, these issues extend far past Shinseki's tenure, earlier than the Obama administration, and earlier in fact, than even the wars in Iraq and Afghanistan. 

There is no excuse for the negligence that we, as a country, have demonstrated in caring for our Veterans. But politics aside, the difficult truth is that there are a number of intersecting issues that are creating the VA wait times and care backlog. On the supply side, there is a nationwide shortage of primary care physicians. And the veterans' demand for medical services is simultaneously soaring. As vets are more likely to live from catastrophic injuries, and with vets from Vietnam to Iraq to Afghanistan needing care, the number of outpatient visits to the VA has grown by 26% in the last 5 years (with medical staff growing by only 18%). Primary-care appointments have grown by 50%, while the department’s staff of primary care doctors has grown by only 9%. And across departments, doctors are supposed to be responsible for 1200 patients but are caring for 2000. (See article here.)

Of course, as the New York Times reports, "Republicans say the problem is not a lack of money — the department’s $154 billion annual budget has more than doubled since 2006 — but rather inefficiencies in the delivery of care. Democrats say that the problem is a serious shortage of doctors and not enough hospitals." Either way, the problems for the VA delivering timely and quality healthcare is related to medical providers being asked to do too much with too little (whether that lack is of time, support, or money). Which is something that all medical providers can surely empathize with.

So what are the VA and its committed medical providers to do? If anything, pressure is increasing for quick fixes to a problem that is constrained in large part by numbers of patients, number of doctors, and severity of medical issues. One fix that we see is to use telemedicine to leverage the time and energy of the providers that the VA has. 

If the VA shortage of providers and resources resonates with you, these are some ways that telemedicine may be able to help: 

• Telemedicine can drop readmissions and length of stay. Surprisingly, medical collaboration -- like that facilitated by telemedicine -- can improve numbers on both readmissions and length of stay. 
• Telemedicine can save providers' time they're spent on care coordination. Most providers will tell you what this study proves: huge amounts of time are spent outside of patient care, coordinating care and waiting for patient data. Telemedicine, particularly hybrid store-and-forward telemedicine, can slash those wasted minutes and get you the data you need when you're ready to receive it.
• Telemedicine can loop in providers that are outside the system, but within a single patient visit. Of course, the most obvious use of telemedicine -- to enable consults with other providers even within a single visit -- is still a fantastic way to leverage provider time.
• Telemedicine can enable more providers to collaborate on complex cases, efficiently. Especially with the complexity of cases that the VA is seeing, multiple specialists and providers across the continuum of care are needed to care for a single patient. A medical collaboration platform will help you integrate all of these voices so that patients don't have to bounce from visit to visit with long wait times between each.

Looking for a telemedicine solution in your organization? We can help you sort through the options:

Image courtesy of dvids on Flickr, used under Creative Commons rights.

Medical decisions have a lot of variables. As we treat our patients, we consider everything from the impact of a treatment on the patient's job, to the opinions of colleagues and family members, to the patient's own goals and values. It's never as simple as "we're going to do this because this is the indicated course of treatment."

Most medical providers see patients in a hospital, clinic, or practice. But as university sports programs become community cornerstones, the "patient" is also the "student" and the "athlete." So athletic trainers (and the healthcare providers that collaborate with them) have many roles to juggle. Because of my observation of athletic trainers' artful juggling of these roles, I wasn't surprised to see a recent article on the limitations that university sports teams and their medical trainers face in treating their student-patients. University sports programs, especially the most successful, often have legitimate 7-figure deals with companies like Nike, Adidas, and Under Armour. These deals exchange logo exposure for fees paid to the sports program.

With so much money, careers, health and university survival on the line, sports programs face hard decisions in choosing treatments.

Problems arise when a medical treatment -- such as spatting -- interferes with the visibility of a logo on a player's shoe or uniform. "With the NCAA battling multiple lawsuits regarding players' inability to profit off their likenesses and the long-term health effects from football, the ankle joint becomes where commercial and medical interests can be at odds."

Something like spatting, in which the ankle is wrapped outside of the shoe to increase stability and prevent or care for an ankle injury, may not seem like a very big medical issue. But when an individual's livelihood depends on the performance of their ankles to support them, as is the case with many student-athletes, even simple medical issues have complex ramifications. In fact, although many sponsorship contracts prohibit or limit spatting because it covers up sneaker logos, it is an effective treatment for many ankle issues. "A 2009 study published in the "International Journal of Exercise Science" studied 17 subjects during warm-ups and 60 minutes of touch football and found spatting to be more effective than taping at limiting range of motion. A 2011 study from researchers at Drake University published in the same journal found spatting and taping together to be as stable as bracing." Plus, strategic issues come into play: "Although many of the contracts prohibit it, a player with one injured ankle might get both spatted to prevent opposing teams from targeting the injured ankle." (Both references here.) 

Further complications arise because, for college athletes, the contract is not between the athlete and the sports company -- it is between the team and the sports company. So decisions around a course of treatment can be somewhat distanced from the individual player's interests and decisions -- medically, personally, and financially.

Team trainers, athletic directors, and a team's sports medicine providers face all the complexities of any medical provider -- plus a set of business, educational, and sports considerations. 

We believe that conversation and collaboration can help manage these colliding interests, and thus reduce the athletic trainer's headaches. What about those of you who are athletic trainers? How have sponsorship contracts affected your ability to treat patients? We'd love to hear more about your experience in the comments below...

And if you're curious how telemedicine can support your sports medicine program, click below for your free guide on telemedicine pros and cons...

Image courtesy of 41992695@N04 on Flickr, used under Creative Commons rights.

Collaboration in Response to Disaster

It's hard to imagine the devastation of a large-scale disaster like that of Typhoon Yolanda in November of last year.

As the New England Journal of Medicine reports, an Israeli medical team that arrived in the days following the storm found a pretty desperate situation. Throughout the Philippines, more than 5,000 people were confirmed dead and 22,000 were still reported missing. Upon reporting to the hospital, where the Israeli team was to work, they found 120 hospitalized patients, no electricity, no running water, and an Operating Room with a staff of 2.

The World Health Organization guidelines suggest that a team like this one should set up their own hospital, not integrating or collaborating with teams on the ground. But the Israeli team had a strong sense that an unintegrated path wouldn't be the best course of action. Within hours, they worked with the Philippine hospital and local resources to create an integrated plan for medical collaboration.

And within 10 days, this collaborative, transnational team of medical providers deftly dealt with 2,686 cases.

What allowed them this kind of success in such difficult conditions?

This brave team gives medical collaboration takeaways anyone can learn from:

• Accepting resource limitations. We all have limited resources, and sometimes these limitations can seem insurmountable. For this team, however, giving up was not an option, so they accepted their resources and did whatever they could within them. 
• Being willing to go against protocol. Despite the WHO guidelines, this team decided to collaborate and integrate. It was a risk, but it seemed like the right thing to do for the patients, so they went with it. Their success was their reward.
• Open communication and quick decisions. One of the most important pieces of this story is the way that decisions were made quickly, but with transparency, and good communication. Sometimes people think that communication has to be sacrificed for speed. But this high-pressure situation shows that good communication actually facilitated a speedy response.
• Clear lines of responsibility. We've covered the ways that clear lines of responsibility decrease length of stay and drop readmissions. Similarly, having very clear roles and responsibilities helped this team quickly triage and treat, without duplication or gaps in care.

As the team said, reflecting on the experience: "Following a cooperative model may pose some challenges… In this instance, however, by relinquishing our well-established habit of operating as a highly independent unit, we found that, when feasible, a cooperative model can have additional and important benefits for the victims of a disaster."

For more medical collaboration stories and strategies, get our Quick Guide to Medical Collaboration:

Image courtesy of ihhinsaniyardimvakfi on flickr.com, used under Creative Commons rights.

2012 is gone, 2013 is coming. Are there any trends in telemedicine and medical collaboration that are clear? Can we look beyond the scary fog?

Three aphorisms come immediately to mind:

• Franklin Delano Roosevelt: “The only thing we have to fear is fear itself”
• Yogi Berra: “ It ain’t over ’til its over”
• Dorothy in Wizard of OZ: “Toto, we are not in Kansas anymore

Sometimes an aphorism is all we can hang on to as we look ahead into a fearful fog of uncertainty. As we ask ourselves what happened in 2012? And, what is ahead in 2013, it is difficult to find answers. Here are a few observations of events, and then a brief discussion of where all of this fits into the last 50 to 75 years as our world changes.

A few attitudes changed in 2012:

• California passed its telehealth law.
• Emailing pictures is expected by patients.
• Enforcement of HIPAA and HITECH laws increased.
• An election took place, Obamacare (Otherwise not known as the Affordable Care Act of 2012) moved forward.
• Big Data became interested in health care.
• Connectivity in the USA increased.
• Providers became busier.

A few attitudes did not:

• Store and forward telemedicine is not explicitly paid for by CMS
• EMR and EHRs were pushed into use, and costs increased.
• Technology fatigue remained.
• People still need the right care at the right time in the right place.

• It is acknowledged, by everyone both inside and outside “the system,” that health care is a mess.
  

ClickCare had some exciting moments in 2012:

• Thousands of collaborations on behalf of the patient.
• A couple of lifesaving collaborations.
• A prominent article in the NY TImes.
• Some great Blog coverage.
• A shout out from “Santa Woz” at the American Telemedicine Association Meeting 2012.
• The meeting of new friends, customers and business partners.

Can we find a larger context for what is going on in health care?

Consider this thought by C. Otto Scharmer, Theory U Leading from the Future as it Emerges. There are three global shifts of humankind worldwide.

1. The rise of a global economy
2. The rise of a networked society
3. The rise of a new consciousness, a cultural-spiritual shift.

As you read the following, and if you are old enough, remember, or young enough, study, some events that you have seen or heard about: Martin Luther King, the sexual revolution, Betty Freidan, the fall of the Berlin Wall, on-line shopping, search, social media, jet travel, a friend in a foreign country, war in far off villages. In each case, in just 25 to 50 years, a massive and common shift has occurred. And the shift focuses on the individual. 

There are many good things about these shifts, Sharmer explains, but they have also created three types of poverty: economic poverty, sociocultural poverty (a loss of inner values with a culture of materialism), and spiritual poverty (a loss of connectivity with our neighbors while we become world wide more connected). These have resulted in a backlash and a restructuring of society. Fundamentalism, human rights, feminism, struggling capitalism and failing socialism, and environmentalism. 

In the setting of health care, the backlash is in the form of regulation which is essentially distrust of one's neighbor, even if that neighbor is a healthcare provider. The backlash is also a distrust of the individual. Further, a culture of materialism is fostered by a system which declares professional courtesy or discounted service for the poor (exceptions for individuals) to be fraud. While we are connected with social media, we are also increasingly forced into silos of activity and silos of knowledge. The new cultural spiritual shift is driving people who wish to give, to justify their activity, by what they take. Giving freely is suspect because free has been monetized and no longer is free.

With a concerted effort, the good will triumph over the bad. The networked patient can become part of their own care—not by dictation of “meaningful use 2," but by the sheer ability to participate. The networked society can be augmented and nourished, not crushed and made illegal. The global economy can be recognized and engaged, not ignored and isolated.

We see providers who are members of the emerging “creative class” returning to the basics of good care and rejecting the constraints of federal initiatives. The materialism of CPT codes will be replaced by a commitment to good care. We will see patients accept illness and not accept being labeled as consumers of medical care, but rather providers. We will see problem solvers try to use technology in a way that is right and proper, not reimbursable and archaic. We see ClickCare empowering the individual patient and the individual provider to work together with each other and with colleagues to provide access to care, collaboration and support of each other, and education of healthcare students of all types. Hierarchy and rules will be broken down. The backlash will resolve and the movement toward the empowered individual will go forward.

We see a better 2013 than 2012.

Attribution and References:
Fog and Hound:
http://grizzlybomb.com/2012/01/11/bbcs-sherlock-season-2-episode-2-the-hounds-of-baskerville/

Betty Friedan:
http://en.wikipedia.org/wiki/Betty_Friedan
Schlesinger Library, Radcliffe Institute, Harvard University
http://www.nytimes.com/2006/02/05/national/05friedan.html

Theory U:
C. Otto Scharmer, Theory U Leading from the Future as it Emerges, 2009

Accountable Care is a payment and delivery model that relates quality and cost. It is conceptually very similar to the HMO models of the 1970s. Interestingly, the same players have rejoined the game.

Tallies are made on three items:

• Appropriateness
• Efficiency
• Quality

At first reading, these are undeniable truths, but further thought brings untenable falsehoods.

They are significant, and both the process and the products arehighly questionable. 

• Where are the Carl Bernstein’s, Jacob Riis’s, and Robin Cook’s of the world? Why does the Affordable Care Act (Obamacare) feel as complicated as the disease of the system itself?
• Why have thousands of lobbyists participated in a process that leaves the individual citizen/patient overwhelmed and under-informed.
• Why must discussion be brought down to sound bites?

Instead of sound bites, let’s focus the fundamentals of health care. Let’s focus on patients and those who care for them. When it comes to paying and payors, it all becomes too impersonal, too murky, and frankly, too suspicious. Maybe the healthcare system has become so complex, and so inter-twinned, and so self-interested, than no one Bernstein, Riis or Cook can take on the investigation that is needed. Still, fortunately, questions are being raised.

All of that said, and all of that needed, we each can do our part. Our warning is about quality. Not quality itself, but about defining quality. Our concern is that to measure quality one needs numbers. To get numbers one needs definitions. To get definitions on needs language. To get language one needs ideas. And that is where the problem lies. Ideas can be new or old; accepted or controversial; hackneyed or original; common or cultural. 

It is naive to think that judging data will “incentivize” quality. What is measured, indeed, is what is changed, but when an institution (government or corporate) measures things, its citizens and employees fill out whatever form is offered to get the reward, and most often do not accept the penalty to reach a higher good. Can complete, comprehensive empathetic care be measured by ICD-9 or ICD-10?

For instance, is "incentivize hospitals, physicians, post-acute care facilities, and other providers involved to form linkages and facilitate coordination of care delivery" really collaboration? Who benefits? Is the patient or the ACO at risk? Is doing nothing good or bad? Does compromise of treatment, because of a compromised patient, acceptable.

This is not a new debate. Thus the reminder is that the patient must be the final beneficiary of quality improvement. It is the patient who sits before you, places trust in you, and ultimately lives or dies because of you. True quality is getting the best data available (yes even from an EMR/EHR) and then doing your very best, as an individual with an individual to get he best answer. This requires true medical collaboration on behalf of the patient. Collaboration requires exchanging data, experience and judgment. It is an extra effort. It takes work—in the past telephone tag, long and inaccurate descriptions, and long meaningless “reports and consults” from  “incentivized” consultants were bad enough. Not to be out done, primary care providers now send a 12 page EMR referral with every single checkbox filled in. Nobody thinks, they just generate data, devoid of interpretation, and without understanding.

Now, iClickCare makes it much better and easier. We must not jump over the bar that is given to us, but instead consider what is needed for the patient in front of us, and raise the bar for ourselves. iClickCare empowers the part of ACOs that matter for the patient -- patient centered collaboration.

References:  

(1) McClellan, Mark, et al. A National Strategy to put Accountable Care into Practice. Health Affairs. 29(5). 2010. 982-990.

(2) http://capsules.kaiserhealthnews.org/index.php/2011/10/nixons-hmos-hold-lessons-for-obamas-acos/

Could iClickCare be a distraction?

On December 14, 2011 Mr. Matt Richtel in the NY Times wrote about electronic devices when placed (forced?) into the hands of medical providers resulted in unintended distractions.

Many, many comments followed. Some fearful, some indignant, but all observing use and misuse of computers and smartphones. A dramatic mention of a neurosurgeon who was involved in a malpractice suit after using a wireless headset during surgery... clearly typifies abuse. It is sad to see colleagues who have much training but little judgment. A humorous advertisement shows the absurdity of such practice.

Any tool can be used for creation or for destruction. The ball-peen hammer is a necessary part of a tool box, and an oft used prop in murder mysteries. The EMR/EHR is cited in the comments. The electronic medical record should be a help, but judging by the comments in Mr Richter’s piece which we agree with, it has become more than a distraction, it has become a liability.

That is ironic since the EMR/EHR was in part designed to “document” in an litiginous environment where appearance trumps reality. Could it be that this misapplication of technology is worsened by a subtle, but well advertised, push to document so billing can be justified (or maybe enhanced)?

We at ClickCare are heavily invested in using technology to make things better for both patient and provider. We also remember the student who is left totally behind by expensive costs of EMR/EHR “seats.”  We are aware of distraction, and we are dismayed by anything that interferes with the provider/patient relationship.

Our design principles follow this rule: that technology be assistive, simple and delightful. So when you see your doctor, your nurse, or yourself pull out an iPhone or stare at a screen and see iClickCare, be confident that you are involved in medical management that is supportive and exciting. Beeps, clicks, fields and page flips are minimized and distraction changes to problem solving.

Let me tell you a story about how these how these three resolutions for the New Year came to my mind.

My beeper went off for the emergency room on the day after Christmas. I was called to suture a chin laceration on a 14 year old middle linebacker who fell while ice skating with his sister.

After a couple of relaxing days off, I was shocked by the stress shown on the dedicated faces of the staff, from triage nurse to provider to aide. The sad part is that the stress was not from a sad death or a worrisome epidemic. It was due to our medical system-gone-bad where care for the patient has been distorted from care to “through-put.”  The pressure to perform, measured by quantity rather than quality, has become pervasive. Such quantity, of course, is supposed to be documented in our electronic health records which are often of dubious value to the problem at hand. We are victims of a broken system, but, we can control ourselves.

So here are the three resolutions that came to mind and hopefully will make the next year happier for us all.

1. Be kind 

2. Be collaborative

3. Be inventive

Of course, you are already trying to be kind to your colleagues. It is not their fault that they are grouchy, stressed, superficial, or non-communicative. Arrogant specialist or non-expert primary care provider... cut each a little slack.

You already want to collaborate with your colleagues. It makes you feel more relaxed, more confident, more efficient, more satisfied  You regain time for yourself from: telephone tag, cognitive clutter, or followups. You regain time from inefficiency and redundant work. You receive the satisfaction of having done the right thing.

Since you are the one in the trenches, you are often trying to be inventive. It is you who have the experience. Fix a little thing for yourself and you will fix it for others. The government wants your help. http://www.innovations.cms.gov/initiatives/innovation-challenge/  We can’t fix everything, but we can fix some things, and together maybe we can make a real difference. We welcome you to share your ideas with us via email or this blog.

This goes along with what JFK said: Ask not what your country can do for you, ask what you can do for your country.”  Just this new thinking may relieve stress for you and your colleagues in the new year. And further, we've attached Chapter 1 of Medical iPhone Photography for taking better iPhone collaborative clinical pictures to relieve your stress even more. After the holiday season, the full version is sold on Amazon (and the App Store and Barnes & Noble), in both electronic and Deluxe Paperback Edition.

The holiday season is descending up on us.  How do you know that? Two ways:  

1. Christmas carols on the office radio. 
2. Everyone starts writing on the on-call calendar, trading, prioritizing, discussing.

Telemedicine can make this easier or harder. One way to make it easier is to to be sure that you sign out your telemedicine responsibilities just as you do your patients. On-call and coverage are issues. Continuity and coordination of patient care are others.

Who is “on” is a big deal.  So big, as a matter of fact, that we found more that 20 words to describe it. We are sure that you have heard that Eskimos have 100 words to describe snow.

Hawaiians similarly have many words to describe the emotions of the ocean (full disclosure: some think that  this is an urban myth, see (http://en.wikipedia.org/wiki/Eskimo_words_for_snow). Hawaiians have many words to describe the many emotions of the ocean; these words describe their close relationship to their environment.

But have you thought about the fact that nurses and doctors have over 20 words for on-call and coverage?

In our solution, as we enter the crucible of the holiday season, we offer a system that lets users build there own coverage groups and on call notifications. Try to explain that to software engineers. We found that our everyday terms aren’t explicable to very smart people, and our developers are, indeed, very smart people! So, in order to help us clarify what we wanted to say, we started to place the very simple terms into a table. After a few minutes we had added row after row, and discovered nuance after nuance.

We even remembered, that in the modern day of medicine, there is yet another phrase: “Post-Call.” This is a phrase that makes collaboration and ClickCare even more important.

Please look through the table below and add your own words about call and coverage in the comments. But remember, as difficult as it may be, this is a family oriented site, so don’t offer the words that you really use when you have to cover and have to be on call! With great discipline and restraint we, ourselves, were very responsible and even controlled!

This week is Nurse Practitioner’s Week!

• Nurse practitioners number more than 148,000.
• Collaboration is central to their mission.
• ClickCare was born because of a nurse practitioner.

Congratulations to the more than 148,000 nurse practitioners who work in hospitals, schools and offices.  As they do their day to day tasks, they are contributing a solution to the health care shortage.

Nurse practitioners have always been models for medical collaboration.  Each nurse practitioner has made a special effort to learn more, get extra schooling, and pass more tests. We of course salute these efforts.

Even more so, we salute their commitment to collaboration with their patients, with their co-workers, and with their collaborating physicians.

Did you know that ClickCare was especially born and designed from such collaboration?  A nurse practitioner, one of the first in the area, in 1995, was placed in a school-based health clinic. She recognized that she had a challenge ahead of her. Understanding the goals of the school-based clinic, she wanted to keep the children in school even if a medical problem came up. Understanding that telephone conversations are empty and hollow, and telephone tag, tortuous and inefficient, she asked: “If only I could send the doctor a picture?”

It was hard; it was slow; it was expensive; it was also so very exciting! And it was the first school-based telemedicine program in the United States.  1995 has lead to nearly 2012.  The school-based program continues, but now, it is no longer slow; it is no longer hard; it is no longer expensive; but it is every bit as exciting and even more!

We look forward to continuing to help nurse practitioners as our medical system changes and as we provide a unique collaboration and communication tool which allows them to serve better.

And in the spirit of “If only I could send the doctor a picture”  download our growing book on using the iPhone for medical and clinical photography.

  You can learn more about nurse practitioners here.