Being Mortal

I just finished reading Being Mortal: Medicine and What Matters in the End, by Atul Gawande, MD.  I wish my father were alive to have read this book; he would have thoroughly appreciated the themes it covers.  As a small town private practice family physician, he lived them.

In Being Mortal, Dr. Gawande works through what happens at the end of our lives, and how we should best respond to it.  It's a question that is not discussed as much as it should be, and he makes several excellent points.

Death is a very different experience in the era of modern medicine than it used to be.  Society has gotten good at preventing many of the things (medical or social) that used to kill people when they were younger, which means we are much more likely to endure the decline which becomes inevitable as our bodies age.  But we as a society are not really ready to cope with that.  Medicine's desire to address discreet problems does not address the systemic issues that become the real issue for people as they age.

In a Norman Rockwell America, the elderly remain in the home with one of their children.  But in the end, that proves not to be a practical solution.  Because children have long since moved out of the parent's home, it's not remaining, but moving into their children's house.  And as the care needs escalate, those needs inevitably become more than a child/caregiver can provide.

Dr. Gawande discusses what assisted living started as, a place that can care for the infirm without institutionalizing them.  Much of the discussion in the book is around what is wrong in most nursing home care and end-of-life medicine - that there is no interest in individual desires, just efficient care-giving.

The solution, both in housing and in medicine, are in more a whole-person approach.  Real assisted living, palliative care, and hospice all work to use that approach.  The key factor is a willingness to discuss what is important to the person as they age and lose some of their capabilities.  The author cites a 2010 study by Mass General Hospital offered that palliative care in addition to treatment to ½ their patients with Stage 4 lung cancer.  “The result: those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice care earlier, experienced less suffering at the end of their lives—and they lived 25% longer.  In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality.  If end-of-life discussions were an experimental drug, the FDA would approve it.”

We are reminded that medicine and institutions are designed to promote safety and longer life.  But the sick and the aged have priorities beyond merely being safe and living longer.  I am a staunch advocate of hospice, mostly because it provides care that is sensitive to those real priorities.

Dr. Gawande concludes by saying that:

"Our job in medicine is not to ensure health and survival, it is to enable well-being."

He's right, and hospice and palliative care are the services that currently address that.  We need a medical system where ALL care providers are focused on enabling well-being, and not simply addressing whatever immediate medical need there is.

Read the book.  Engage in discussions with those you love about their end-of-life desires. You will be happy you did.

Tele-monitoring for Chronic Diseases - The Numbers

Finally, a study summarizing all the other studies done over the last several years.

The evidence is overwhelming.  Using technology in the home of patients with chronic diseases reduces hospitalizations, emergency room visits and overall cost.

This overview analysis focused on studies that deployed some telehealth mechanism (tele-monitoring-monitoring in patient's homes, video-conferencing, nurse telephone interventions) for patients with a chronic disease, specifically,  congestive heart failure (CHF), stroke, and chronic obstructive pulmonary disease (COPD).

As an aside, it is interesting to note that as early as 1879, there is anecdotal evidence of diagnosis over the telephone.  A physician listened to the cough of a child who was thought to have the croup, and determined that the child did not.  The concept of medicine being delivered without a doctor present has been around longer than we might have imagined.

The studies included in this analysis took place from 2000 to early 2014.  After examining hundreds of reports, this analysis found 19 CHF studies, 21 stroke studies, and 17 COPD studies that met their criterion for size and completeness.  There were some experiments in video medicine, telephone check-ins, and tele-monitoring.  The consistent conclusion is that doing something while the patient is not actively in the medical system improves outcomes and saves money.

As the authors say:
The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/readmissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

It's past time where we should be debating this.  It's time to implement telehealth at every health system that is interested in better outcomes at lower cost.

Thanks to the folks at Advanced Telehealth Solutions for bringing this study to my attention in their blog.

Home Care

I’ve already written about hospice and tele-monitoring.  Home care is the obvious third leg of the non-acute care stool.  For patients that are at home, and can’t get anywhere else, providing care to them in their home is significantly more attractive to them and to whoever has to pay the total bill than having them go without care, get worse, and finally need a visit to the emergency room.

Medicare alone spent 78 Billion Dollars on home care in 2012.  It’s a big business.  But is certainly is not being used to the fullest.  It is interesting to note that although there is a lot of discussion these days about our payment systems evolving from fee-for-service to some sort of Outcomes Based Reimbursement, home care under medicare has been operating that way since 2001.  The system is called PPS (prospective payment system) and basically gives home care agencies a flat amount for a 60 day episode of care.  The amount of that payment is determined by the answers to an assessment (OASIS) designed to determine how difficult that patient will be to care for.

Home care has made this system work for them for over a decade now.  Providing good care to people in their homes has avoided some hospitalizations, and has allowed some patient to stay in their home, rather than have to move to a facility.

Traditionally, health care systems have not put much emphasis on home care.  Even hospitals that own home care agencies frequently don’t have a good handle on how that business works.  In the past, with separate payments, hospital visits avoided by home care did not necessarily benefit the bottom line.  Going forward, they will.  That means large health care organizations that don't own or affiliate closely with a home care agency will have higher costs.

Like so much of what needs to happen in health care, the need to use home care more is just plain old common sense.  Let's hope health entities begin to catch on to that.

Open Notes

A very interesting article on the benefits of patients reading the notes their doctors write about them

Hospice

Again, my view of the future of health care predicts payment systems will evolve so that we are paying for health care, not just disease management services rendered.  There are a lot of statistics about the small percentage of the population with chronic diseases taking up most of our health care dollars today.  It’s the 80/20 rule, only more so.

That topic does warrant further exploration, but today I wanted to talk about the amount of money spent at end of life.  Inordinate sums are spent at the end of people’s lives, with no measurable improvement in quality of life, and frequently very little increase its length.  Money magazine measures end of life spending at one quarter of Medicare dollars spent on health care.

The interesting thing about this topic is that the solution is already in place.  Hospice became a Medicare reimbursable service in 1982.  By 2013, approximately 14 Billion dollars on hospice care.  But that would have been more if those patients had not elected hospice.  Hospice is already not fee for service.  Agencies receive a certain amount per day, and are expected to provide total care for the patient.

The patients are kept comfortable.  The patients are kept at home.  The family is taught about the disease process and the grief process.  I have never talked to a family that has gone through this that didn’t love their hospice agency.

All this, yet it costs the health care system LESS than conventional care.

How can we get our technology obsessed culture to accept that every extra day of life, full of tubes and wires and gadgets, is not a day better?  How can we let families have the peace of an ending without beeps and bells and fluorescent lights?

My father was a small town family physician who went on to be a Navy doctor and administrator for the last part of his career. We have a close family, and most of us write. Vertrees wrote about his brother's passing in the late 80s, and his words are just as true today:

A PIECE OF MY MIND

My oldest brother, Donn, born in 1923, died recently. He was one of the brightest, most intellectual people I have ever known. He spent his life as a teacher, first of high school students, then of life and living it to congregations of Protestants. In the course of his travels around the world, running schools, he contracted intestinal amebiasis. He dated his "troubles" to that onset (whether it was causative is anyone's guess), but by 1984 he had significant idiopathic ischemic myocardiopathy with an ejection fraction of 17% on cardiac catheterization. He was dutifully told of the dismal prognosis, the lack of utility of surgical treatment, and made peace with himself and others around him. He did not, however, succumb ... he simply became more feeble and had less reserve (of every kind). He and his wife therefore went to China to work in an import/export business that required someone of integrity, but with little stamina, to be on-site. This exposed him to a far different type of medicine and an altogether different outlook on life. It seemed to strengthen his already somewhat mystical approach to life and its vicissitudes. 

He came home to rest in the early '90s, whereupon his friends and congregation built him a parish house in which to relax and continue to teach every other Sunday to a small but devoted crowd. In March of 1995 he began to require the benefits of our modem, high-tech medical care system. 

Beset by the usual uncertainties of reliance on and access to a generalist, he and his well-intentioned family/advisors sought out care and treatment from a series of highly-skilled, technologically-attuned, subspecialty-trained physicians. Singly and in groups they were caring, conscientious, thoughtful and careful practitioners of their art. No one of them remained in charge long enough to develop a "long-term" view, nor did any assume the mantle of total responsibility for planning the "what we will do, how long will we do it, and what should be the desired outcome" kinds of issues. Between March and November, I would estimate that roughly $3-500,000 were expended by various third parties as he bounced from one physician/facility to another (Donn had no funds, save Medicare coverage; it wasn't something about which he worried nor for which he had remotely prepared). Some shifts in care were geographically induced (sick while away from home), some occasioned by well-meaning but non-efficacious advice ("I know someone with that problem and Dr. Soandso did a wonderful job"; "Have you tried the [fill in your own favorite, he heard them all] Clinic?"), and some precipitated by a caring-but-guilt-ridden family, who could not bear to see him suffer the multi-systems effects of failing heart ("Someone else must be able to do something!").

I visited him as I could, pressed by my own agenda and hampered by distance. We talked when he felt like it and I listened to the clamor of those facing the daily task of giving kindness to a soul losing its way. I expressed my own mordant, experience-generated recommendations, but they were too strident and to-a-point which others were not ready to accept (though Donn was, I thought). By well-intentioned people he was diuresed, digitalized, after-load reduced, ultrasounded, thallium-stressed, MUGAed, scintigraphied, cathed, bypassed, dobutamined, cardioverted (some of these several times) by each new steward of his diminishing ship of state. He even had his pleurae scarified, to lessen the constant, terrifying effusions. He was finally sent home. with kind Hospice accompanying and morphine, the only succor and tool that could really allow him to slip away in a "care and comfort" mode. 

I muse on these events, in my current role as a resource allocator in a large healthcare system. No one meant for the cost to be so great, nor the outcome so poor; no one, given the clarity of the retrospectoscope and the chance to do it again, would have done all that was done. The man should have been allowed to sit on his porch and die peacefully, much earlier then that event actually happened, I think to myself. Is it any wonder our current system is wildly expensive? Are there really malice, ignorance and mean-spiritedness rampant in our field of endeavor, or has the decision tree not been properly written in our medical schools? Must politicians, lawyers, business people (a euphemism for "bottom-line" types) and nitwitted journalists be our guides from this thicket? I hope not! But unless each individual physician seizes each individual case by its medical and fiscal throat, we shall have none to blame but ourselves. Must the solution require team-think? Are we so fractioned, so limited in our personal outlooks that we have no room for the group/national needs vice those of the individual patient? These are hard choices; my immediate worry, as I spoke to the panoply of folk rend(er)ing care, is that the consideration of allowing life to ebb as a natural process was not even considered, nor discussed among the professionals or the family. Yet these are good, highly-trained, altruistically-motivated people, not charlatans.

Should we allow uncaring actuaries to read us a list of “whens," or should we seize the moment to think about this, at the crucial time in each case, which all physicians (of whatever stripe) can recognize more capably than anyone else? 

Donn and his hard-pressed family are resting now. Someone else (all of us!) has borne the cost. New patients are daily brought to CCUs in similar straits, none easily diagnosed/prognosed prospectively. The escalation of expenditures, balanced against the immediacyl"non-cost"(!) of one more test/procedure, make easy decisions impossible. Change is all about us; one case makes little more than another anecdote ... but this one is very personal to me and my current position. How will we handle the next one? Better, I hope; one step at a time, I guess. 

Vertrees Hollingsworth MD

Clinical Associate Professor of Family Practice F. Edward Hebert School of Medicine

Uniformed Services University of the Health Sciences

Bethesda, Maryland 

My father was admitted to hospice in August 2011, and died in his sleep at home on February 14, 2012. No extraordinary measures at all, and that's the way he would have wanted it.

We need hospice in this country, now more than ever. It's the right thing for the patients and family, and it's the right thing for our health care economy.

Telehealth

Telehealth
What does that word even mean? To many today, it means virtual visits – being able to see your doctor on a computer screen, avoiding the drive to the office.  There are even companies creating special rooms to allow you to see a specialist remotely.  Also, you may hear about “store and forward” telehealth, which means taking a picture/video, and it gets sent to your care provider securely at an appropriate time, basically fancy email.  But the part of telehealth I really want to talk about is tele-monitoring.

Tele-monitoring (or remote patient monitoring) is using devices to gather health information, usually vital signs, and sending them to a centralized system so they can be monitored.  Many of the systems that gather that information can also provide reminders and education to the patient.  The beauty of these systems is that they require no scheduling between patient and provider, and they let the patient feel in control.

Why is now the time to build a program around RPM?

RPM no longer costs extra
Coverage of tele-monitoring is still rare under fee for service, but value based reimbursement allows users to recoup the investment.  Watch the documentary “Escape Fire”.  US medicine is finally beginning to move toward incentives for health care.  The old model of simply paying for doctors to do more can’t be sustained.  And once the provider’s reimbursement is tied to keeping the patient well and avoiding expensive hospital care, Remote Patient Monitoring essentially becomes reimbursed, because it saves more money than it costs.  Study after study has shown patients stay healthier and avoid re-admissions while on a tele-monitoring program.

The technology is better
It’s finally time.  Apple’s iWatch may make the technology even better, but it is already good enough to have working, inexpensive, unobtrusive equipment in the patient’s home.  We’ve come a long way since I was part of a company that tried to do this in 1994.  Back then, we were desperate for workable equipment.  We tried to use the Apple Newton.

We used a PC from an Atlanta company that made an all-in-one for < $1000, back when that was cheap and special.  Eventually we contracted with a device manufacturer in Boston create a special device.  It was still a little bulky and cumbersome; we even had to build a box to hide all the wires.  But even with that, we had success in the patient's home. Nowadays, devices use Bluetooth connectivity to send measurements to a hub.  The Hub connects over a cellular network to send data to server.  The server data is accessible via web.  Systems are less expensive, more reliable, and there is a lot of competition.

Medication compliance
The CDC measures that 20-30% of prescriptions are never filled.  And 50% are not taken correctly.  This imposes tremendous costs on the health care system, estimated at between $100 Million and $289 Million.  In-home reminder systems, text alerts and other mechanisms are available to improve medication compliance.

People (patients) like it
We are beyond the point where only gadget lovers are interested in tele-monitoring.  Systems have been proven to work, and patient satisfaction with programs is high.  As an added bonus, having telemonitoring in the home increases patient engagement, which can help satisfy Meaningful Use.

So, we finally have payment systems starting which align the desire for better, lower cost care with the revenue coming in.  And we have the technology to monitor vital signs in the home and intervene as necessary.  We can improve health care and improve the bottom line.  If you are involved in a health system that isn’t talking about Remote Patient Monitoring, I’d love to talk to you and help you get there. The time for telehealth is now.

VA Scheduling software

Jon Daily hits it dead on.  All good humor is based on truth.
http://thedailyshow.cc.com/videos/r9nm2k/v-a--men--delays-of-future-past