Do we really want people to get better?

‎”I know zoos are no longer in people’s good graces. Religion faces the same problem. Certain illusions about freedom plague them both.” – Pi, Life of Pi

Many illusions and religious zealotry permeate the health-care debate, which is a very complex problem even when stripped down of such sensationalism.  On this topic, here is a nice blog entry by Paul Levy from 2011 but still relevant today.

Not Running a Hospital: Religious dogma

Thoughtful analysis of the barriers to our health reform efforts.  I agree we in the profession are focused on “doing services” as opposed to “creating outcomes”.  As Steven Levitt of Freakonomics says, “It’s all about the incentives.”  We don’t incentivize outcomes, we incentivize doing “stuff” to “patients”.  From a technical standpoint, I get paid every time that depressive patient comes back week after week to see me, I do not get paid once they feel better, are “cured” and stop coming.  Now, yes, that is a simplistic view of the process, and I don’t know any psychologists or psychiatrists or other mental health professionals who approach their practice in this manner (ok, maybe just a few, but they wouldn’t admit as much).  There is a general belief that as we help one patient move on, others will need our services.  I believe that such ethical practice and goodwill is the strong majority across these disciplines.  But, having said that, as a system at the macro-level, the incentives are still not there.  Why not incentivize mental health providers to help patients develop noticeable, measurable, concrete outcomes towards improving their lives?  This is nothing new, yet systemically we can’t seem to make the leap.  And then there’s the pharma industry where the question remains are they incentivized to cure or incentivized to maintain illness at livable levels?

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Transition to Telemedicine- Revolution or Evolution?

We live in an age of rapid acceleration of technology, dissemination of communication, methods by
which that communication can be disseminated, and the requirement for us to keep up.  We are raising a cohort of children who will be challenged (or rather they’ll do just fine, but challenge us) to think increasingly in non-linear, digital, expansive, and algorithmic ways to understand and solve the problems they face. The video games and smartphones of today lay the groundwork for that future- in true Apple style it is training them to “Think Different”.  It usually takes just one observation of a two year old first navigating an iPhone or iPad, and how quickly and intuitively that child picks up the navigation, to see how quickly they will surpass us (at least us middle aged dinosaurs).  Thus, it’s easy for us anywhere from 30 years old and up, to see these changes over the past 10 years as revolutionary, and we in the helping professions are particularly at risk to view these changes in like manner.

However, let’s give pause for a second and reflect on this.  Transition to telemedicine is Revolutionary for health care practitioners, but it is merely Evolutionary for patients.  Said another way, that transition is one Giant leap for the health care industry, and one Small (and natural) step for patients.  We need to be careful not to assume the patient understands the complexities faced by us providers.  They don’t care, beyond how it impacts their care, the ease with which they can obtain it, and the positive life outcomes it can deliver.  Revolutions are revolutionary to those running them and effecting change, but to the poor farmer who just  wants better crop yields, a fair price at the market, and consistent food in his families bellies it is simply a welcome change, because after all they have crops to tend to at sunrise tomorrow.  We have to be careful not to get too caught up in the revolution and lose focus on the main goal- cost-effective service delivery that improves clinical outcomes, and mostly improves patients lives.

I am reminded of a post by Seth Godin, the first is, for me, a take on T.S. Elliot’s classic Poem “The Hollow Men “

This is the way the world ends Not with a bang but a whimper.

I would rephrase this to . . .

This is the way health care reform begins, Not with a bang but a whimper.

Godin blogs briefly and succinctly about how we win one small victory at a time- Preparing for the Breakthrough/Calamity.  The big announcement, the big plan, the big reform memo does nothing.  These are merely the War Bond drives before the battle, they help, but they don’t win the battle.  This insight is verified in Jim Collins’s research on Fortune 500 companies in his seminal book “Good to Great”.  The big launch party of a new logo does not change cultures, corporate or otherwise, it is the slow and steady slog in the day to day behavior that effects lasting change.  Or, what I like to refer to as the banality of change. In clinical practice and in health reform, that is how the change will come in any positive, lasting, and meaningful way, one small improved outcome at a time.  Technology can advance or slow that process, but it should not drive the process in-and-of itself.  Rather, patient outcomes, accessibility, and cost-effectiveness, need to drive the process.

Godin writes elsewhere,

“You can jump up and down and sing and dance and launch fireworks, but if the consumer’s story of pain is vivid enough, you will be ignored. When the house is on fire, all your audience wants is a hose.”  

When our patients are languishing without proper access to treatment, diagnostics, affordable medication, differential diagnosis, psychiatric beds, and so on, the promise of health care reform means nothing if not delivered in a meaningful way.  I was recently at a State mental health conference where many “well-learned” folks from several government offices talked about the exciting changes in mental health care reform, economies of scale, MCOs, ACOs, EMRs, EBPs and so on.  It was certainly exciting talk, but there was a sense that all the talk was focused on OUR excitement, and it failed to drive down to how we are going to help the individual- to help that patient with chronic schizophrenia gain access to care more easily despite his paranoia; how that mother of four   working three jobs with a special-needs child can gather additional support without traveling to three different clinics and taking excessive time off of work or time away from her children; or the Iraqi war veteran who struggles to adjust upon return home, as he and his wife try patching back together a marriage tested by distance and trauma.

These are the realities our patients live in, they really don’t care about our Powerpoint presentations.

That’s my take, I welcome your thoughts . . . .

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Leveraging Telemedicine to reach rural patients, but not in the US

Wonderful article about leveraging technology to reach rural patients, and cut health costs dramatically.  But, the catch?  Not here in the USA, not just yet.  This article describes an innovative, and really cost-effective, way to help treat peritoneal dialysis (PD) patients in rural India.  So often in telemedicine, we consider leveraging the technology to mitigate, or minimize, or replace the procedure; or we think of such to increase access to specialists — both which reduce costs.  In this particular case, those are technically true, but the technology is used to eliminate a barrier which then opens up access to a much more cost-effective treatment for PD.

Yet, this same approach can be leveraged and implemented across a range of behavioral health applications- pain clinics, bariatric surgery clinics, primary care, crisis “1st responder” coverage for mental health agencies, school rapid response threat assessment, off-shore and distant location operations that require behavioral health consultation, and so on.  The irony is that we have an abundance of resources here in the US, but in some ways lack the vision to implement existing technologies in novel ways.  We have plenty of vision to develop new technologies, new EMRs, new portals for connectivity, but sometimes we fail to see how the age-old wheel can be used in a new way.  This vision is equally important as inventing a new wheel.

The real trick is not to entrench ourselves into thinking linear- where technology simply replaces or supplements the existing provider framework.  But the trick is to see how it opens up new possibilities, and removes existing barriers, that can go beyond “hyper-porting” a doc from here to there.  This is only the beginning . . .

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Telemental Health Efficacy clearly demonstrated

We all may agree that the Government does some things well, and some not so well, but it appears the VA System implemented their telemental health program strongly in the right direction.

In this landmark study on Telemental Health Efficacy, nearly 100,000 patients from 2007 to 2010 who utilized telemental health services showed a dramatic decrease (24% reduction) in psychiatric hospital admissions, in relation to a compare group who received traditional face-to-face interventions.  The study also found a 27% reduction in total bed days at a psychiatric facility, again compared to those who were engaged in traditional services.

Improved access, flexibility, and rapid response availability were key factors at play, further reinforcing what many of us have known for years- namely, that there is often a limited window to engage mental health patients in crisis or in pre-crisis, and once that window closes patients are likely to flounder until full blown crisis erupts.  By “getting in” earlier and with greater flexibility, clinicians are able to circumvent that crisis cycle and reduce the intensity of the crisis episode.

In this regard, the VA system is quite cutting edge, as they have surpassed the predictable SOLE use of psychiatry for medication management, and incorporated telemental health services delivery across all spectrums and interventions- individual, group, family, and couples therapies.  Of note, the most resistance wasn’t from the patients, it was from clinicians (and dare I add in administrators)- any surprise there.

Patients are more flexible and adaptive then we often give them credit for, and they just want help.  When in the water up to their necks, they don’t care if you don’t throw them a certified life ring, as long as what you throw them floats.  Our challenge is to continue to push the boundaries of this new service delivery while also developing reasonable guidelines and parameters to foster it’s safe and effective use.

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Choice and “The Creative Destruction of Medicine”

Great article by Brian Dolan of Mobile Health News, “How medicine will be Topol’d“.  A quick review of Eric Topol’s new book, “The Creative Destruction of Medecine“.

I just started reading the book, but can say I think it’s certainly forward thinking and bold, yet not too far out there.  I agree with Topal that we’re at a peculiar time when the technology and its potential application for medicine as a whole, significantly exceeds the understanding of the averaged patent OR doctor.  There’s some real good stuff out there we could use now with just a little change to our  mind set, and then there’s even more interesting stuff we could use in the near future that is sort of mind blowing- but both are unknown to the average citizen.  In essence, it’s a marketing problem, and one of the reasons Topol wrote the book was to bridge that gap.

He speaks to net-based communities of patients who trust each others feedback more than their physicians input, and in many respects that may be accurate.  Over time I think medicine has lost it’s bed-side manner and attention to the patient as a whole person, and with that loss so goes respect and unquestioned authority.  Having said that, there is another factor more of a psychological nature that remains unattended- namely, the propensity of the individual to want “an authority” to take the big choices off their hands.  In an age of information overload (which is only getting worse), we are quickly surpassing the problem of “how to I get good information” and entering a problem phase of “how do I filter the information to distill what I need.”  People say they like choices, and in an age of rapid globalization we often assume that means unlimited choice, but in reality people like the “perception” of choices.  People really want reasonable choices that can be digested.

Barry Schwartz, sociologist at Swarthmore, nails it in his TED talk on the “Paradox of Choice“.  He poignantly illustrates that we used to be able to pick one of maybe four pairs of Jeans at a store, and in general we were happy with that.  Now, we have almost hundreds of options, and we are miserable.  Why?  Because in an age approaching almost limitless (or seemingly limitless choice), we worry if we chose correctly.  And when our choice options exceed our ability to mine  the data and weigh the options, then we are basically functioning in a  realm of limitless choices.  If I have a choice of 100 TVs to choose from,  but really can only research 10, then it doesn’t matter whether you give me 12 options, or 50, or 1,000.  They are essentially limitless because I cannot review them all, there always remain the “what ifs”, and thus there lies the gap between what I can make an informed decision upon, and the abyss.  And the abyss keeps us up at night.

The professional- doctor, lawyer, interior designer, web designer, personal trainer- narrows those choices for us and gives us the impression that we’ve weighed what is out there vis-a-vis their extensive awareness of the knowledge base at hand.  That is the one factor that I’m not sure Topol considers, or many of the tech folks (I aspiring to be one of them) who see nothing but rapid acceleration where tech meets patient meets medicine.  I fear they are overestimating the patient’s, the individuals, ability to adapt in a world of seemingly limitless information and choices.

We shall see, I hope I am wrong.

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Telemental Health in Involuntary Commitment Proceedings

I think Government Health IT got it right in their article, “Five years from now 2011 may be looked at as a pivotal time in the evolution of Telehealth.”

Federal funding is rapidly increasing, as are reductions in logistical barriers.  Technology is moving faster still with a proliferation of mobile devices and apps, as well as increasingly user friendly EMRs and other types of interface to make the telemedicine experience as seamless as possible.  The technology is not holding us back, and also less and less are the funding barriers (yes, there are still some significant barriers, but if you look at the energy around accessing more funding both public and private, I think the funding issue will quickly become palatable).  The real factor holding telemedicine, and in particular telemental health, back is the Human factor.

We are the main barrier now.  Our openness to change, our openness to new technology, our ability to envision creative ways to bring this marriage of technology and clinical outcomes to fruition.  The good news is this isn’t sweeping, but it is occurring in significant pockets.  A quick example from my home state North Carolina.

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A quick digression, in N.C. as in many other states, the process of involuntary commitment has 2 or 3 key parts.  This is a streamlined version but captures the key points.  First, someone (anyone can do this) must file an Involuntary Petition (IP) affidavit with the court (typically Magistrates office) claiming someone (referred to as the respondent) is a danger to themselves and/or others.  This requires a citizen to present to the court/Magistrates office, sign an affidavit, and have it notarized.  For professionals working in a facility such as an ED or Crisis Unit, most jurisdictions allow the doctor (psychiatrist or doctoral psychologist) to do the IP remotely on site and fax it in (thus avoiding having the doctor leave the unit and drive down to the court, which is a smart accommodation), yet it still requires a notary to witness signing of the IP affidavit.

If the court authority agrees they approve the IP, issue a Law Enforcement Agency (LEA) pickup order, and officers from that jurisdiction go out to locate the respondent and bring them to a designated facility to undergo a psychiatric evaluation.  That evaluation is called the “Initial Qualified Physician/Psychologist Examination” (1st QPE).  This location can be an ED, a Crisis Unit, or even an outpatient clinic in some circumstances.  In N.C. (except for unique pilot areas) a psychiatrist or doctoral psychologist must perform the 1st QPE.  Once completed, the doctor can decide to release the respondent home, or to continue the IP and send the respondent to a psychiatric inpatient hospital.  If the latter, once the patient is transported to the psychiatric inpatient hospital, a 2nd QPE is conducted by a psychiatrist to confirm admission.  As an aside, in almost all cases if the 1st QPE concludes hospitalization is needed, the 2nd QPE concurs.  The respondent can then be held up to 72 hours prior to having a hearing, if they so request, to contend their hospitalization.

Another nuance, quite often when a doctor is working in or with a facility, they may do both the IP (affidavit) and the 1st QPE simultaneously.  This is quite common when patients present to these locations on voluntary basis but have imminent risk factors present that require acute psychiatric hospitalization.

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The N.C. Legislature amended the Involuntary Commitment Statue in 2009 to allow for the provision of the 1st QPE for involuntary commitments through means of telemedicine.  A wonderful and forward thinking move.  Yet, there were no such changes or adoption to the notary requirements to file an IP.  In N.C., at least presently, a notary must be in the face-face, physical presence of the individual who they are witnessing sign the IP affidavit.  Thus far, telepresence does not count.

For the non-professional initiating the involuntary petition process, this is a non-issue as they are required to go to the court anyway to file the IP affidavit.  Yet, for doctors already working in and with EDs or Crisis Units, and now for those who may be assisting those locations providing the 1st QPE reviews remotely via telemedicine, this creates a conundrum.  Namely because it requires the remote doctor to get a notary to sign the IP affidavit.  This is quite difficult to do at 3am if the doctor is responding from a home office, or from his/her clinic office.  To line up notaries to be “on call” for such contingencies is quite cost prohibitive, and this cost would undoubtedly be passed on to the main facility contracting for the doctor’s services.  Yes, there are limitations to what a notary can charge for their signature (i.e., to notarize) but there are no limits for travel and time.  What would you charge to be awoken at 3am, drive across town, to notarize a legal document?  So here is an example where the Legislature made  a real good move to allow 1st QPEs to be done via telemedicne, but didn’t understand the full human-factor flow of the process.  To really make this work, an update on the notary requirement would be needed, to allow telepresence to be considered face-face interaction.  This is quite common and used increasingly in the court systems, where sworn testimony is taken over a telepresence medium.  Routinely, courts are regarding telepresence functionally the same as face-face interaction.

This is just one example of how our current ways of thinking need to evolve along with the technological aspects of telepresence, in order to allow such to reach its full potential.

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Medical Mistakes

A quick share . . .

Very interesting TED talk about the strive for perfection in medical practice, the shame that goes with making mistakes, and the avoidance of admitting such with absolute denial.  Doctors Make Mistakes, Can we Talk About That?

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