The Road to EMR: Expect the Unexpected
The administration has filled the media with promises that a fully-operational electronic medical records system will be up and running soon, within ten years at the outside. Most feel this is quite do-able and David Brailer, the National Health Information Technology Coordinator (see bio in our April issue) seems to be the man to get this important job done. He is talking to everyone, meeting with every group, always stressing that we have to immediately get on track if patients and practitioners are -- soon as possible -- going to reap all the waiting-to-be achieved advantages of an IT healthcare system.
But words of caution are always needed and worth considering. A recent issue of the Journal of the American Medical Association highlighted two articles that seem to point the way to move carefully and carefully plan ahead. Especially in these early IT stages that we are going through now. In that way practitioners and patients have the opportunity to readjust their care-giving and care-receiving habits to the changes that IT are starting to make.
One report was based on a two-year study of a computerized physician order entry system (CPOE) that was put in place at the U. of Pennsylvania School of Medicine. The researchers gave the system what they thought was ample time to "get the bugs out", then surveyed 261 staff members, conducted 5 focus groups and held an unrecorded number of one-on-one interviews. Included in the study were doctors, nurses, pharmacists and IT staff.
Conclusions were that the amount of instruction given and the time devoted to planning and implementing the switchover simply wasn't enough for things to immediately work smoothly. Some CPOE displays actually blocked a coherent view of several patients' medications…some pharmacy inventory displays were totally in error…rigid ordering formats occasionally confused the physician's orders.
In all, researchers claim they found 22 individual and specific ways that a computer system -- specifically designed to aid physicians -- could result in medication errors.
A portion of the switchover problems were placed on staff misunderstanding of some element of the system. But conclusion was that the major problem was software that wasn't sufficiently "user friendly"…because it simply was not able to immediately anticipate every aspect of the history, thinking and needs of both the patients and the various levels of caregivers involved.
The second article in the same issue was a bit more forgiving, at least at first glance. It analyzed one hundred trials of computer systems specifically designed to help physicians more-quickly and more-easily diagnose their patients' ills. The software designers who developed the systems thought they were working well from the start. But in an editorial analysis, a senior professor at the U. of Florida College of Medicine called them "….as much experiments as they are solutions". Conclusion: much more planning time was needed; much more joint system analysis was needed between the producers and the physician-users.
When asked to comment on the articles, the ever-alert Dr. Brailer called them "...a useful wake up call." Which seems to mean: move ahead as fast as possible, but only if it can be done as smartly as possible.
The Road to EMR: Guard That Firewall
Looking for a tool to gather information that could just-possibly lead to her reinstatement at Oakland's Kaiser Permanente HMO, an angry former employee apparently found a method to "get even" instead. She claims that merely going through Google -- and with an apparently lucky click or two -- she accessed some degree of confidential internal patient information. She then posted a link to a web site that contained basic facts about 140 patients; just to show that she, or anybody, could do it. The good news is the details released by the former employee were limited to general rather than specific medical information.
Kaiser first learned of her actions early in the year through notification from the U. S. Office of Civil Rights, which is the enforcement arm that works with HIPAA. The company went to court seeking a restraining order but no immediate decision was reached and the matter was in limbo for several nervous months as the legal process dragged along. The ex-employee -- Elisa Cooper -- promised to post no more information until the matter was adjudicated; nevertheless, the company recently heaved a sigh of relief when a preliminary injunction against additional postings was finally issued by the court.
Ms. Cooper refers to herself as a former Kaiser "web coordinator". She says the posting was done in an effort to call attention to the potential mass breach of privacy laws which she blames on Kaiser's lax handling. A Kaiser spokesperson says the data released included patient names, addresses, even phone numbers... but that more-specific care and treatment information was hidden behind a well-guarded medical records numbering system.
However, routine lab information was also posted for several patients. Ms. Cooper says she is not a "hacker" and was merely doing a general search of company files, still looking to dispute her two-year-old termination. She claims that she also accessed a site that contained diagrams of Kaiser systems, as well as more-confidential patient data…claiming these were not protected by a password or a firewall.
Kaiser, on the other hand, says it knows of no way such information could be gleaned by chance and is investigating its internal processes to see if it -- just possibly -- is responsible for the former employee's ability to enter a restricted and apparently well-protected area of their data base…which covers over eight million members.
However, there has been at least one other such slip-up at the west coast giant; the incident occurred in 2000 when a staffer inadvertently sent confidential medical information on 858 patients to 17 uninvolved other patients. Outside our industry, Bank of America, LexisNexis and ChoicePoint have recently been apparently involved in major IT information "leaks".
Polls Apart
Yet another survey seems to prove that Americans continue to have much the same love-hate image of the pharmaceuticals ...only more so. A recent survey conducted by a major healthcare industry "think tank" found big numbers on the plus side, with 78% of adult respondents applauding prescription drugs because they made a "big difference" in most people's lives. In fact, over 90% felt that the companies' continuing research and development programs made life better for most people.
But then again…70% of these same respondents thought the pharmaceutical companies do most of this good work simply because they are so strongly profit-driven. With that in mind, 65% of those surveyed said they favored more government control in the pricing area, and more than 70% just wanted to be able to buy cheaper drugs from Canada.
Conclusion of the pollsters is that -- deserved or not -- the pharmaceuticals and their product pricing are also seen as the biggest cause of steadily-rising healthcare costs. Only 19% accepted the industry's mantra that high current drug prices today create the funds needed to research and develop ever-better drugs in the immediate future…and only 18% believe the sometimes wondrous claims for specific drugs can generally be accepted as true and unbiased.
Celebrity presenters, such as Dorothy Hamill for Vioxx, are now generally greeted with great skepticism.
Incidentally…pharmaceutical advertising reportedly jumped by 30% -- to $4.35 billion -- in the twelve month period ending November 2004. Add sampling, detailing and any number of other sponsorships in any number of promotional areas and the industry's overall sales-support figure most likely tops the $25 billion that was reported in 2003, the last year such data was made available.
Patients in Peril
There apparently is another side to the TV-based stories of medical helicopters plucking patients out of impossible places and rushing them to a hospital for life-saving care. Point is, helicopters also crash; not too often, but often enough for a second look. Last year eighteen people -- patients, pilots and paramedics --were killed in eleven such accidents.
Once it was an elite industry and nearly all of these copters were affiliated and run by prestigious hospitals. But, at the turn of the century, the feds ruled that charges for ambulance services -- ground and airborne -- must stand alone; till then they were usually "bundled" into the basic set charges paid by all patients. This simply made it too expensive for the too-few, and most hospitals decided they could no longer support such a service. Presenting an opportunity for entrepreneurs to seek new markets for their copter services.
Today there are about 700 "air ambulance" units operating on a regular basis across the country; that's double the number of a decade ago. The industry has grown rapidly and competitively, but most say with too little regulation.
Many think there are no longer enough high-skill medivac pilots to go around and too much of their equipment in general and their electronics in particular are out of date and not too-well cared for. Medivac trade groups, on the other hand, say the increase in accidents is caused to a great degree by the increase in helicopter use.
Currently there are approximately 350,000 medivac flights yearly. About 30% are answers to highway accidents or other emergency situations. Surprisingly, most of the remaining flights are patient transfers from one hospital to another. The cost of such airlifts range from $5,000 to $8,000. That averages five times the cost of an ambulance, yet most of these flights are surprisingly covered, at least in part, by Medicare and private health plans.
Both the FAA and the National Transportation Safety Board are currently trying to step in with sound suggestions for new standards that hopefully will improve flight safety. These can basically be summed up in just four words: better training, better equipment.
"Pacemakers" Expand
To treat other parts of the body. And to do it at a reduced size and weight.
For close to fifty years, those implantable electrical stimulators that are simply called pacemakers have helped millions of patients maintain a steady and correct heartbeat.
Today smaller and sleeker models are being tested as possible controls for a variety of far-from-the-heart conditions: urinary incontinence, migraine headaches, epilepsy, erectile dysfunction, back pain, the tremors of Parkinson's …even depression and eating disorders.
Size has been reduced markedly, which is one of the major reasons the pacemakers are now being tested in so many parts of the body. Average weight of a device has gone from 2.5 ounces to as little as a single ounce.
Today's more-sophisticated electronic circuitry enables physicians to fine-tune pulses to a degree never imagined. In fact, a "mini-micro" unit weighing less than half an ounce and measuring about the size of an inch-long strand of spaghetti has been inserted, by needle, into the base of the skulls of nine patients suffering from extreme migraines. Initial results were mixed, but definitely on the positive side.
In the face of all these possible severe illness cures, the units may achieve their broadest successes in the obesity area. Clinical trials are now being conducted across the country to learn if electrical stimulators in the stomach area can help morbidly obese people more-easily shed lots of weight. Its purpose is -- by using electrical impulses to decrease appetite -- to act as a safer and easier alternative to gastric bypass surgery.
Moving Overseas
Minnesota was the first state to offer a web site -- RxConnect -- designed to guide residents looking for less-expensive mail order drugs that can be reimported from nearby Canada. Now that the pharmaceuticals have tightened their distribution in an attempt to eliminate most cross-border sales, Minnesota has enlarged RxConnect to include two British pharmacies which would offer drugs produced in Italy, Spain and Greece.
Minnesota's website currently links to four mail order pharmacies in Canada…which reportedly have filled over 10,000 prescription since January, 2004. Now they are ready to move into untapped territory.
As a first step, the state's Department of Human Services has issued a 14-page report covering Europe's pharmaceutical system, which they say is as safe as any in the world. They are also working on a plan in which their current Canadian pharmacy contacts -- their own supplies being held on a "short leash" by many of the pharmaceuticals -- will import drugs from overseas and then resell them to Minnesotans.
Many outsiders, though, question what real effect all this effort will really have in cutting the overall cost of medicines to its citizens.
Minnesotans reportedly spend over $2.7 billion on prescription drugs each year; they have purchased just over $2 million through RxConnect since January 2004.
Doctors in Danger
A recently-released study - restricted to the state of Michigan -- found 76% of emergency room doctors that responded to the questionnaire reported they had been subjected to verbal abuse by patients in the previous year …and that 28% of them had actually been assaulted. About 12% had been verbally or even physically attacked outside the ER; close to 4% reported they were stalked. Almost 20% of these doctors found it prudent to obtain a gun and another 20% decided to carry a knife, even though most emergency rooms have strict rules about physicians carrying weapons while attending patients.
It gets worse because this survey - just-reported in the Annals of Emergency Medicine -- took place in 2002! General conclusion is that things keep getting more violent every year.
The study's lead examiner and author of this report is the director of emergency medicine at the University of Michigan/St. Joseph Mercy Hospital in Ann Arbor. He unequivocally states that, in his opinion, these percentages will hold up in hospitals across the country, perhaps across the industrialized world …primarily because so many violent patients have to be brought to the ER by the police.
Though extra guards on duty apparently help, a Phoenix hospital has come up with a simpler and they feel quite-efficient deterrent ….a well-trained "K-9 type" German Shepard on a tight leash. They report that a couple of well-sounded barks will usually cower the rowdiest patient.
Cancer Care: New 3-Way Support
The dreaded disease may meet its pharmaceutical match sooner than expected. This hope is apparently based on three factors.
The first is due to the remarkable technological advances as mapping of the human genome, which literally opened a world of knowledge to researchers. Secondly, it has apparently been targeted as the next great economic opportunity for the pharmaceuticals, that at present are developing less than the expected number of blockbuster drugs needed to maintain an investor-satisfying bottom line. And finally, the FDA has agreed to expedite approval of drugs for cancer and other most-serious, most life-threatening diseases; mandating instead an agreement that the drugs must be closely-monitored after initial approval is received.
Currently Bristol-Myers Squibb, AstraZeneca, Wythe, Merck, Glaxo, Pfizer and Novartis are all devoting more time and extra staff to cancer treatment. Novartis has a treatment for a rare form of leukemia on the market for several years and Bristol-Myers has a relatively-new treatment for colorectal cancer; both are needed by small segments of cancer patients, but both are hugely expensive.
Pfizer has now designated cancer treatment as the second-largest segment of its research budget. It has a narrow-range product ready to file for FDA approvals. If it passes additional tests -- as Pfizer anticipates - this product most likely will soon thereafter be approved for a broader range of cancer care. Which they see as win-win for both company and patients.
Wythe reportedly has a kidney cancer product which isn't quite ready to seek approval, but Novartis has its own colorectal cancer drug apparently ready to seek approval by year's end. Merck has an inoculation for cervical cancer that it plans to apply for FDA approval at about the same time.
Finally, in the high-volume area, Glaxo has eight cancer treatment drugs in its research pipeline…plus one vaccine and three therapeutic vaccines.
Coding Tips
Amyloidosis is a disease process that encompasses a large amount of conditions, and is distinguished by the build-up of a group of diverse proteins called amyloids that accumulate in tissues and organs of the body. Amyloidosis may be limited to one specific area, may be generalized, involving an entire organ, or may be genetic or familial. For example, amyloid deposits may bind to the capillary walls of the glomeruli, causing renal amyloidosis, while amyloidosis of the aging is characterized by amyloid deposits in the nervous system and heart tissue, and may be associated with dementia and severe congestive heart failure.
When assigning codes for amyloidosis, assign first the code for the disease, code 277.3, followed by additional codes for other organ involvement, including lung involvement, code 517.8, heart involvement, code 425.7, amyloid induced nephropathy, code 583.81, amyloid induced neuropathy, code 357.4, and code 713.7, which includes amyloidosis with joint involvement.
Transcription Tips
Mispronunciations in dictation are frequently encountered by medical transcriptionists. Of course, terms should be spelled correctly and NOT as they are (mis) pronounced. Pay attention to spell and grammar checkers to help spot misspelling and incorrect forms: D: adnexae, T: adnexa; D: aeriation, T: aeration; D: orientated, T: oriented; D: pharnyx, T: pharynx; D: diverticuli, T: diverticula.
Quit-Smoking Breakthrough
Apparently the world's most widespread addiction is in for a real battle as giant pharmaceutical companies and small startups are touting the fact that they may have finally found the "stop" button -- in pill form -- which will work quickly, effectively and permanently for everyone that wants to kick the habit. The drugs seem to do their job by mimicking or blocking nicotine's chemical reaction on the body. Pfizer researchers claim they have identified a brain receptor that nicotine binds itself to and has created a drug which attaches itself to the same site, effectively eliminating the craving. Early stage; the company is currently planning to seek FDA approval and initial trials. The French pharmaceutical company, Sanofi-Synthelabo, expects to request initial FDA approval later in the year for the drug rimonabant which targets the circuitry in the brain that invites smokers to keep lighting up. If it all works-as-planned, this drug might also be used to reduce overeating and to treat alcohol and drug abuse. Meanwhile a small Florida company, working with an NIH grant, is apparently ready to go into stage III testing with a drug that triggers the production of antibodies that bind nicotine molecules and thereby blocks their ability to affect the brain. And apparently there are any number of others working towards a similar goal.
Medical Minutia
The science of pathology was founded by Giovanni Morgagni in Padua, Italy in the latter part of the seventeenth century. Working without a microscope, he detailed the pathological appearance of diseased tissue in over 700 cases.
He published -- at the age of 79 -- a series of medical case histories which explained and illustrated the damage done to the body by aneurysms and other barely-understood diseases of the heart and the liver. Marginal note...surprisingly, the microscope wasn't introduced into the pathology lab until the early nineteenth century.
Auditing the News
John Halamka is an emergency room doctor who spends most of his time doing CIO chores for Harvard Med School and Boston's Beth Israel-Deaconess Hospital. He is currently using himself to make the point that an implanted RFID chip -- about twice the size of a grain of rice -- can enable healthcare workers to immediately get essential medical information from a seriously-ill comatose patient.
The chip was implanted in Dr. Halamka's upper arm in a five-minute procedure and can be scanned by a radio frequency identification reader to access his records which have been electronically stored. Dr. Halamka's objective is to use himself as a showpiece that will convince others to have the same procedure.
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The long-sought move to ICD-10 CM is stalled yet again, even though both AHIMA and the AHA have consistently stated that this updated system would provide more accurate data and be better suited to the fast-approaching electronic world.
Problems revolve around potential increase of costs…which have been estimated all the way from $425 million to $1.5 billion by a RAND study. Two years ago, the Blue Cross and Blue Shield Association put the figure as high as $14 billion!
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Coming to Philadelphia's convention center June 19…the biotech industry's 13th annual convention. Reps from sixty countries are expected, along with corporations and government people at various levels; over 1,400 booths are anticipated.
Though all the big pharmaceutical companies will be represented, this is more of a planning-information-business meeting, with speakers talking about drug safety, stem cell research, how the FDA's role should expand or contract.
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The move to "paperless" patient records recently moved up a notch. Elizabeth's Trinitas Hospital announced-with-pride that it is the first hospital in New Jersey to fully activate the Sunrise Clinical Manager…providing a visual, computerized snapshot of each patient's tests reports and condition.
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Surgeon General Richard Carmona, MD recently projected that by 2010, half of Americans over 50 will be at risk for fracture from osteoporosis and low bone mass. Unless middle-aged and older people increase the quality of their diet (including recommended doses of calcium and vitamin D)… do some real exercise most days…and take their medications.
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Blood and urine tests for illegal drug use may soon become a thing of the past, replaced instead by less-invasive, easier-to-accept saliva testing techniques that are currently in use by several European law enforcement agencies. Researchers have found that these oral fluids are at least as accurate, since what is found in the blood is also found in saliva.
The developers say that drug users have learned a number of ways to beat urine tests; but so far no way has been found to beat "oral fluids" tests.
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According to a report in Life Sciences, an ancient drug called artemisinin has been modified to specifically attack cancer cells. Cancer cells take up more iron than normal cells, making them more susceptible to the toxic effects of this drug…which is derived from wormwood and is normally used to treat malaria in several Asian countries. This is all earliest-stage research so far. Animal studies are the proposed next step.
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The nationwide construction boom of children's hospitals continues to grow; 41 of America's 250 children's hospitals are building or renovating. Latest is Chicago's Comer Children Hospital which is lauded as both tops in medical services and their friendly approaches to both the kids and their families.
Comer has 42" flat-screen TVs in each patient room, a no-parents-allowed rec room, juke box, pinball and video games. Plus pullout couches for parents staying overnight.
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The Office of Naval Research is funding the development of technology that may greatly improve communications between ambulances and hospital staff, effectively placing "virtual doctors" on board the "buses". Current test models use varying international maritime satellite frequencies, plus multiple cameras inside and outside the ambulance, to enable ER staff to observe, monitor and evaluate care while the seriously-ill patient is still in-transit.
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The first major advance in heart attack care was recently announced at a conference of the American College of Cardiology. Reported…immediately administering ER heart attack patients with Plavix, in addition to the usual clot buster drugs, reduces by roughly one-third the chance that the patient will die or suffer another heart attack before he or she can be fully tested and evaluated for possible surgery.
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