By Donald E Bittner, MD
Treatment algorithms is not a new concept, thousands of physicians go through this concept every time they treat patients. The problem is that the physician varies off the algorithm due to fear of the outlying entity that may get them sued for malpractice.
By using treatment algorithms that have been accepted as standard of care by all specialty and sub specialty groups, we could avoid frivolous malpractice suits and save billions of dollars due to unnecessary studies and avoidable procedures. The old cliche, if it sounds like a horse, it most likely is a horse and not a zebra is very true. As an example, the use of MRI's ordered to rule out internal derangement of the knee after physical exam are sometimes not necessary. Ninety nine percent of the time, the complete orthopedic exam will give you enough information to appropriately evaluate the knee before an arthroscopic procedure or to treat the knee conservatively. As we all know, MRI studies are not always exact but most of the time they are ordered to rule out the suspected pathology.
Through an already well established legal concept of Complete Legal Defense, we may be able to use the best treatment algorithms to avoid frivolous lawsuits and save billions spent on unnecessary studies and treatment. Every state has Complete Legal Defense with slight variations. Each state could have accepted panels of specialists or sub specialists that could decide if a malpractice case is worthy of Complete Legal Defense. If so, a panel of legal judges could apply the ruling to the case. Only those cases worthy of such a defense would be eligible for Complete Legal Defense, other cases would follow the same legal process for malpractice cases. Through this pathway I believe many unnecessary lawsuits and a significant amount of unnecessary treatments and procedures could be avoided.
Donald E. Bittner M.D.
dbittner08@fastmail.fm
Saturday, October 3, 2009
Sick healthcare system and a doctors approach to it. How can we learn from comparative studies?
By Bijan Sadri MD
Problem solving processes are used in many world activities. Businesses use the process to decide on the ways of gaining more profit. Governments use them to gain more control and power. Doctors also use them to treat patients.
Each may use slightly different approaches to this process.
Being a doctor I want to see if the process of patient management can also help us manage and correct the sick healthcare system in the US.
To put it in a very simple way, approaching a patient starts by asking the patient for the problems that they have. Then we continue by doing a thorough inquiry into previous problems and then examination of the patient and asking for Para clinical tests.
In this process you try to ask questions about every aspect of the patient problems and gather row subjective and objective information about their problem.
Thus far in our study group we have also so far tried to ask what problems there are in our healthcare system and listed them.
The difference between problem solving methods in medicine and other world affairs is that medicine relies heavily on the use of medical literature in every step of the way. Problems have already been described and can be retrieved from databases and previous studies.
In medicine you try to paint a picture of problems that your patient have. And you call them syndromes or diseases. It means a group of symptoms that constitute the illness. Then you compare them to the literature and based on that literature and previous works try to find syndromes and diseases that are similar. Physicians devise strategies for correcting problems based on these definitions and advices of those who have previously studied syndromes.
This is different from the top down approach of problem solving where you treat patient’s pains as small pieces of problems. And also different from the bottom up approach where you find a problem list and group them and devise a new picture and correct that.
It is different in that in each step of the way you go back to the literature and try to find similarities. This will cut your problem solving time greatly and by using comparative problem solving method. It makes your work more efficient. Basically we try to find similar pictures in the literature.
Now the question is how we can use the medical problem solving method in our goal of solving the healthcare system.
We have thus far started by putting together list of problems and are trying to group them together. A doctor’s approach in this step of the way is to look at the literature and find similarities between these problems and issues and the literature.
For national policy making a good approach is also to look at the literature in each step of the way. But what is the nature of that literature? The nature of that literature is the history of the country relevant to that problem and history of other countries and societies for solving those issues and problems.
For our group the best source of information for now with our very limited time and resource is the comparative effectiveness conference held at UCI.
It is best that we come up with our problem list and when we are attending that conference listen carefully and see if other people in other parts of the world had the same problem in their history and how did they deal with those issues.
Though I should emphasis that at the same time that we are open minded we should stay critical of those approaches.
This might help us greatly by providing us with clearer pictures of the problems that we are dealing with and help us with the already tested and safer solutions to those problems.
Problem solving processes are used in many world activities. Businesses use the process to decide on the ways of gaining more profit. Governments use them to gain more control and power. Doctors also use them to treat patients.
Each may use slightly different approaches to this process.
Being a doctor I want to see if the process of patient management can also help us manage and correct the sick healthcare system in the US.
To put it in a very simple way, approaching a patient starts by asking the patient for the problems that they have. Then we continue by doing a thorough inquiry into previous problems and then examination of the patient and asking for Para clinical tests.
In this process you try to ask questions about every aspect of the patient problems and gather row subjective and objective information about their problem.
Thus far in our study group we have also so far tried to ask what problems there are in our healthcare system and listed them.
The difference between problem solving methods in medicine and other world affairs is that medicine relies heavily on the use of medical literature in every step of the way. Problems have already been described and can be retrieved from databases and previous studies.
In medicine you try to paint a picture of problems that your patient have. And you call them syndromes or diseases. It means a group of symptoms that constitute the illness. Then you compare them to the literature and based on that literature and previous works try to find syndromes and diseases that are similar. Physicians devise strategies for correcting problems based on these definitions and advices of those who have previously studied syndromes.
This is different from the top down approach of problem solving where you treat patient’s pains as small pieces of problems. And also different from the bottom up approach where you find a problem list and group them and devise a new picture and correct that.
It is different in that in each step of the way you go back to the literature and try to find similarities. This will cut your problem solving time greatly and by using comparative problem solving method. It makes your work more efficient. Basically we try to find similar pictures in the literature.
Now the question is how we can use the medical problem solving method in our goal of solving the healthcare system.
We have thus far started by putting together list of problems and are trying to group them together. A doctor’s approach in this step of the way is to look at the literature and find similarities between these problems and issues and the literature.
For national policy making a good approach is also to look at the literature in each step of the way. But what is the nature of that literature? The nature of that literature is the history of the country relevant to that problem and history of other countries and societies for solving those issues and problems.
For our group the best source of information for now with our very limited time and resource is the comparative effectiveness conference held at UCI.
It is best that we come up with our problem list and when we are attending that conference listen carefully and see if other people in other parts of the world had the same problem in their history and how did they deal with those issues.
Though I should emphasis that at the same time that we are open minded we should stay critical of those approaches.
This might help us greatly by providing us with clearer pictures of the problems that we are dealing with and help us with the already tested and safer solutions to those problems.
Tuesday, September 29, 2009
Do we really understand our process for determining the solution set critical to Health Care Reform?
By Mark Roeske
Health Care Reform…so what is it? What exactly is it designed to solve? Who is the real customer? What are the true problems that we are intending on remedying? It’s almost dizzying to hear the rhetoric regarding proposals, winning ‘something’ with an underlying/unspoken theme of ‘who’s side are you on’?
As with any organization, whether it be a business, charity, or even the doctor treating a patient – the root causes of the problem need to be understood – or the solution might be incorrect and the problem will continue. If the business, NPO, etc. and doctor understand the root cause of the problem – there’s a better chance of solving the problem.
There’s a chance here that we are running too fast at passing a bill that we might find hasn’t come close to solving the real issues/goals. Why not stop, understand the issues better, look to each of the players in health care (patients included) for an analysis of the problems – and potential solutions to solve those problems. The risk is our own ‘framing or view of the world – e.g. ‘Who am I, and how do I see the world (problems)’ For example, someone from inside the hospital will see things very differently than that of the patient, insurance company, government representative, R&D department of a Pharma company, etc. We may be tainted by our own view of things where we ‘don’t know what we don’t know. As a result, others/areas are ignored in the process. So, our analysis of the problem must be all encompassing and untainted by personal gain or ‘winning’ a position.
Our group has been formed to try to encompass the above – but we are all human beings, influenced by history, experience and personal motivations. So, we are attempting to filter out the emotions and potential distortions by utilizing a problem solving process that is fairly standard to the business world.
We currently have representation from many (but unfortunately not all) in the health care process – including the patient. We have had a number of meetings to get started on root cause issues – and are presently at a stage where we are combining the long list of problems into major groupings. There is current debate on the high level headings of these groupings – but for this writing – there is a proposal that they are the following: 1. Process, 2. General Care, 3. Social, 4. Payor system/Insurance, 5. Time, 6. Financial/Cost.
We look forward to vibrant discussions ahead – but are looking to the general public and significant players in the system for comments.
Health Care Reform…so what is it? What exactly is it designed to solve? Who is the real customer? What are the true problems that we are intending on remedying? It’s almost dizzying to hear the rhetoric regarding proposals, winning ‘something’ with an underlying/unspoken theme of ‘who’s side are you on’?
As with any organization, whether it be a business, charity, or even the doctor treating a patient – the root causes of the problem need to be understood – or the solution might be incorrect and the problem will continue. If the business, NPO, etc. and doctor understand the root cause of the problem – there’s a better chance of solving the problem.
There’s a chance here that we are running too fast at passing a bill that we might find hasn’t come close to solving the real issues/goals. Why not stop, understand the issues better, look to each of the players in health care (patients included) for an analysis of the problems – and potential solutions to solve those problems. The risk is our own ‘framing or view of the world – e.g. ‘Who am I, and how do I see the world (problems)’ For example, someone from inside the hospital will see things very differently than that of the patient, insurance company, government representative, R&D department of a Pharma company, etc. We may be tainted by our own view of things where we ‘don’t know what we don’t know. As a result, others/areas are ignored in the process. So, our analysis of the problem must be all encompassing and untainted by personal gain or ‘winning’ a position.
Our group has been formed to try to encompass the above – but we are all human beings, influenced by history, experience and personal motivations. So, we are attempting to filter out the emotions and potential distortions by utilizing a problem solving process that is fairly standard to the business world.
We currently have representation from many (but unfortunately not all) in the health care process – including the patient. We have had a number of meetings to get started on root cause issues – and are presently at a stage where we are combining the long list of problems into major groupings. There is current debate on the high level headings of these groupings – but for this writing – there is a proposal that they are the following: 1. Process, 2. General Care, 3. Social, 4. Payor system/Insurance, 5. Time, 6. Financial/Cost.
We look forward to vibrant discussions ahead – but are looking to the general public and significant players in the system for comments.
Friday, September 25, 2009
Why Solving the Access Problem First is a Bad Idea for Healthcare Reformists
By Alexander Strachan, Jr., MD, MBA
As a practicing physician for the last 20 + years in California, I have seen how the demand for healthcare services is the main driver of healthcare costs. As an activist, and recent MBA graduate from UC Irvine, I have been closely following the debate regarding healthcare reform. The dizzying array of solutions by various observers in Congress seems to be driven by a partisan debate regarding whose solution is right, and who’s wrong, and whose will cost more, blah, blah, blah. Unfortunately, many of the talking heads in Congress have never spent a day working a shift in the emergency room or as a hospitalist like I have for the last twenty years.
Before my graduation as a businessman from MBA school, or becoming a physician leader or an administrator or a consultant, I spent twenty years taking care of the sickest folks, primarily paid for by Medicare and Medical. These Federally and State funded programs, respectively, make up the bulk of the medical coverage of the patients that I have seen over the last twenty years.
Now, I have graduated to being a “policy wonk”. Despite working in healthcare as a consultant for hospitals and health systems, I have a very ominous feeling about where the debate has gone recently. Mr. Obama has decided to try to solve the access problem first, and despite being a card carrying Democrat for the last twenty years, I think that this is a really bad idea.
What has driven my practice over the last twenty years has been demand. Demand for services in healthcare is astounding. Emergency rooms are full, clinics are full and hospitals pray to be full. Physician offices are overrun with patients, either in need of or desirous of care…so called services.
“My name is Mrs. Jones, and I would like a second opinion regarding my back pain. Last week, I had an MRI at my doctor’s office, and he said it was normal. However, my back still hurts. Can I have another MRI please?”
What is a practicing physician to do but order it? I have no access to the results of her prior MRI (thanks to the mess that is healthcare IT). If she has a new spinal tumor, not seen on the prior study, she can sue me. She is on a public insurance program, and she has no skin in the game. It doesn’t cost her one red cent to get this test. I barely make $35.00 for the office visit. Is it worth it for me to deny her this imaging test, and risk getting sued if I am wrong, or better and less risky for me to just write the requisition for the test, and go on about my day, and not worry about practicing appropriately, just practicing defensively?
Since an MRI costs about $850.00, let’s multiply the above scenario by 47 million. Adds up to a big number, huh?
That’s why we need to decide whether health care services are a right, or a privilege or an entitlement, before we grant unlimited access to people who have no cost to bear when they demand services from their doctor. Without tort reform, doctors will simply say yes, since we are not protected if we are wrong. Sounds pretty conservative for a liberal democrat, huh?
Alexander Strachan, Jr, MD, MBA
CEO and Managing Director
CrossWalk Consulting Group, LLC
www.linkedin.com/pub/alexander-strachan-jr-md-mba/1/2b8/888
As a practicing physician for the last 20 + years in California, I have seen how the demand for healthcare services is the main driver of healthcare costs. As an activist, and recent MBA graduate from UC Irvine, I have been closely following the debate regarding healthcare reform. The dizzying array of solutions by various observers in Congress seems to be driven by a partisan debate regarding whose solution is right, and who’s wrong, and whose will cost more, blah, blah, blah. Unfortunately, many of the talking heads in Congress have never spent a day working a shift in the emergency room or as a hospitalist like I have for the last twenty years.
Before my graduation as a businessman from MBA school, or becoming a physician leader or an administrator or a consultant, I spent twenty years taking care of the sickest folks, primarily paid for by Medicare and Medical. These Federally and State funded programs, respectively, make up the bulk of the medical coverage of the patients that I have seen over the last twenty years.
Now, I have graduated to being a “policy wonk”. Despite working in healthcare as a consultant for hospitals and health systems, I have a very ominous feeling about where the debate has gone recently. Mr. Obama has decided to try to solve the access problem first, and despite being a card carrying Democrat for the last twenty years, I think that this is a really bad idea.
What has driven my practice over the last twenty years has been demand. Demand for services in healthcare is astounding. Emergency rooms are full, clinics are full and hospitals pray to be full. Physician offices are overrun with patients, either in need of or desirous of care…so called services.
“My name is Mrs. Jones, and I would like a second opinion regarding my back pain. Last week, I had an MRI at my doctor’s office, and he said it was normal. However, my back still hurts. Can I have another MRI please?”
What is a practicing physician to do but order it? I have no access to the results of her prior MRI (thanks to the mess that is healthcare IT). If she has a new spinal tumor, not seen on the prior study, she can sue me. She is on a public insurance program, and she has no skin in the game. It doesn’t cost her one red cent to get this test. I barely make $35.00 for the office visit. Is it worth it for me to deny her this imaging test, and risk getting sued if I am wrong, or better and less risky for me to just write the requisition for the test, and go on about my day, and not worry about practicing appropriately, just practicing defensively?
Since an MRI costs about $850.00, let’s multiply the above scenario by 47 million. Adds up to a big number, huh?
That’s why we need to decide whether health care services are a right, or a privilege or an entitlement, before we grant unlimited access to people who have no cost to bear when they demand services from their doctor. Without tort reform, doctors will simply say yes, since we are not protected if we are wrong. Sounds pretty conservative for a liberal democrat, huh?
Alexander Strachan, Jr, MD, MBA
CEO and Managing Director
CrossWalk Consulting Group, LLC
www.linkedin.com/pub/alexander-strachan-jr-md-mba/1/2b8/888
Sunday, September 6, 2009
Why we NEED Gov't-Run, Universal, Socialized Healthcare Insurance
Everyone is asking -- and now, finally, there's a basic, no-frills, explanation of why we do NEED Gov't-Run, Universal, Socialized Healthcare Insurance:
Why Gov't-Run, Universal Healthcare Insurance is Necessary
This should unequivocally put an end to the dispute ... or does it?
Why Gov't-Run, Universal Healthcare Insurance is NOT Necessary
-Mr. Gray
About the Author
Mr. Gray is a retired independent author. He is writes about Health Care reform, Politics, and a variety of other Current event topics which are relevant to the evolving times of the 21st Century.
src="http://pagead2.googlesyndication.com/pagead/show_ads.js">
Why Gov't-Run, Universal Healthcare Insurance is Necessary
This should unequivocally put an end to the dispute ... or does it?
Why Gov't-Run, Universal Healthcare Insurance is NOT Necessary
-Mr. Gray
About the Author
Mr. Gray is a retired independent author. He is writes about Health Care reform, Politics, and a variety of other Current event topics which are relevant to the evolving times of the 21st Century.
src="http://pagead2.googlesyndication.com/pagead/show_ads.js">
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