FeedSync – I wonder why I haven't seen much buzz about this.  If Dave Winer had come up with it – would it be the cool new thing?  It's going to take a while before we see Microsoft as an innovator – eh? 

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Can we solve these problems with IT?

My fax machine has too many faxes in it every morning


Analog office:  .. My fax machine has too many faxes in it every morning
which my staff put on a pile on my desk and then I try to read them and act on them  by scribbling illegible notes on them and putting them in piles on someone else’s desk. 
Digital office:  My fax machine has too many faxes in it every morning .. which my staff scan into my EMR and then I try to read them, and act on them often using a separate system functionality – so need to leave the “reading” work stream, do the action, then return to “reading”

Reassuring Lab Results just arrived (by fax, mail, local printer, etc)


When I get labs back – most of them are normal.  I can:
Initial them (digitally or pen/paper) and put them in the chart (paper or digital) Tell the patient that “no news is good news” (which is  terrible customer service, BTW)
But some will call (they should!)
So the chart gets pulled (paper office)
And someone calls them back (usually nurse)
And sometimes answers the questions
And sometimes the patient still wants to talk with the provider
So now it comes to me Like 50 other ones
I stay in the office until 8 PM calling my patients back And they ask other questions when we are on the phone Or they are not home so I leave a message So there is a loose end that I have to manage tomorrow.

 I am a specialist – seeing a new patient for the first time.


I don’t have any records – so my nurse or AA calls the referring provider, pharmacy (for medication list), and hostpial (for recent H & P/Discharge summary)
I wait Some of it arrives via fax Most of it arrives tomorrow I call the preferring provider’s office.
 wait The provider comes to the phone
Can’t remember much about the patient
Asks her staff to pull the chart We wait and talk about our kids in College
Our waiting rooms fill up with angry patients and well-dressed drug reps with too much cologne
Chart is “not found” – it must be in a big pile somewhere
We both get frustrated – referring provider hums a few bars from memory. 
We hang up. I make decisions with the patient based on incomplete data
I dictate my progress notes
I sign them (barely review them) when they come back in 3 days from the transcriptionist
They go into the chart (digital or paper)
My staff faxes a copy of my note to the referring provider.

I am a provider writing a prescription for Clarinex

The patient has seasonal allergies

Has tried “everything else”

The drug reps left a pile of these and I gave some to the patient last time she was here

They work “wonderfully”

She wants more

So I write a prescription

Which she takes to CVS 

And they want to charge her $107.50 

Because it’s not covered 

So she calls my office

And my nurse says she’ll work on it 

So she gets the chart 

So she looks up the insurance company (BlahBlah Healthcare)

And then she calls the “prior authorization” phone number 

And waits on hold 

Until a person answers  

Who sends a fax  

Which the nurse gets 4 hours later

And gets the chart again

And she fills out the form on the fax

And she puts it on my desk with a “sign here” sticky note on the signature line – and pointing to the (empty) justification section 

I get it on my desk the next morning  

I fill in the blank sections of the form and put back on the nurse’s desk

Who faxes the form   …

3 days later the patient calls and asks if this is done.

Different nurse pulls the chart and sees the copy of the fax that was sent to the insurance company – so she says yes.

Patient goes to CVS who tries to charge her $107.50 again

Patient goes home and calls the office

Nurse pulls chart again

Nurse calls BlahBlah Healthcare.  Turns out they haven’t processed it.  They will process it and will let us know if it’s denied (They won’t let us know it it’s approved).

Nurse calls patient and tells her to try CVS again in a few days.

Patient gets angry and yells at nurse

Nurse was depressed anyway and quits her job – slamming the door on her way out, hitting a child in the head as he comes in for his 3-year well-child visit.    He is conscious, but has a laceration on his forehead that will require repair.  The kid’s mother says she’ll sue the physician “for everything he’s worth” as she drags the kid off toward the emergency room.

She hits a raccoon on the way home, barely missing an Oak tree as she tries to avoid little Rocky.

She calls her physician and requests some Xanax to “calm my nerves” – beginning a life of dependence on benzodiazepines and poverty.  She stops making payments on her mortgage, loses her home, and was last seen living over a ventilation grate near the Misys offices in New York City.


Mark died yesterday.  What a jerk.  He had an MI and  died – and now Marcie (behind the pole next to Liz) has to clear out the barn and run the company and feed the dogs and be without him. 

That's Mark holding on to the tent pole at my wedding in August 1989.  He's talking with Richie. 

Liz is helping Mark hold up the pole.   When Mark got Married, Richie, Liz and I drove for 20 hours straight and got there 10 minutes late.  Dead Mark.  I hadn't seen him for a few years – but he was the kind of friend who I could call every 6 or 12 months and we would pick up the conversation right where we left off.  Not any more I guess.  :-(  I'll miss you, Mark. 

JAMA — Abstract: Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis: A Randomized Controlled Trial, December 5, 2007, Williamson et al. 298 (21): 2487

Neither an antibiotic nor a topical steroid alone or in combination was effective as a treatment for acute sinusitis in the primary care setting.

JAMA — Abstract: Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis: A Randomized Controlled Trial, December 5, 2007, Williamson et al. 298 (21): 2487

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Informatics Comeptency Evaluation

Let's say you want to evaluate the Medical INformatics Competency of a group of students, IT staff or physicians.

I'm working on an evaluation tool that should be EASY for anyone with these skills .. and a true challenge for those without.   

Take a look at it here. It's a Google spreadsheet so you will have to log in to Google Docs to edit it .. but feel free to do so.

Nasal Saline for Chronic Sinonasal Symptoms: A Randomized Controlled Trial

I've been recommending nasal saline to patients with sinusitis for a while – and this article provides a compelling argument for the use of a neti pot rather than the traditional "saline spray."

Use of neti pots has increased quite a bit lately – largely due to a clinical event known as the "oprah effect."   Forget the RCT as a Gold Standard.  If Oprah advises a clinical intervention – we all should hop on board.

I usually intorduce the concept to patients by showing them the first 60 seconds of this video.  


It's quicker to just ask "have you heard of a neti pot" and if the answer is "no", I flip my x61 screen around and show the video. Why irrigation works. 

This just makes sense.  If there is poo in your toilet – does putting clorox make it go away?  Of course not – you need to flush.  If there are boogers clogging your sinuses – will antibiotics make the boogers go away?  Of course not – you need to flush.

I find that rather few of my patients request antibiotics now for the treatment of sinusitis symptoms.  This is a good thing – since it's rather clear that only a fraction of patients with sinusitis benefit from antibiotics.  Educating patients today will make things easier for everyone in the future.  As we know – physicians overestimate patients' expectations for antibiotics in the first place – Here's a nice summary of the most recent practice guideline on sinusitis treatment. Note a few things:

  • Most patients with sinusitis don't benefit from antibiotics.  Antibiotics benefit only one of 7 patients they are prescribe to for sinusitis.  6/7 of patients prescribed antibiotics for sinusitis gain no benefit from the intervention, and 1 of every 9 patients prescribed antibiotics is harmed in some way by this treatment. 
  • Nasal irrigation is not a component of this guideline.  We'll have to wait for the "post-Oprah" guideline in a few years. This cochrane reivew provides additional insight that saline irrigation is safe and effective.
  • If antibiotics are used, there is little difference between medications re: efficacy.  translation:  don't use expensive broad spectrum agents.  Amoxicillin is fine.  For penicillin allergic patients, use TMP/SMX or erythromycin (250 QID will  minimize GI side effects).

Tags: sinusitis saline neti pot

Open Source, White Plains, Healthcare

Spent yesterday on the 8th floor at 123 Main Street for meetings with Bob Barthelmes - Red Sox fanBob's team.    He's got a great bunch of people together – and it is inspiring to be part of a team that's doing important work in a meaningful way.   Working with a team of smart people who "get it"  and are intrinsically motivated is always good to re-charge the batteries – much like I feel when I go to STFM meetings.  That's saying  a lot, I suppose, since I remain such an "I."

Olivier was among the participants – though  he didn't speak up as much as I would have liked.  Perhaps He's an "I" too.  🙂

He did show me his Smartcard.  Every French Citizen has one – French Health Access Cardand they have had them for TEN YEARS.  One wonders why we can't get even the easy parts right in the US.  The reimbursement structure for health care here is so broken – and – like a virus – this permeates all of how we attempt to deliver health care.  Our IT systems – from the EMRs to the practice management systems – need to be far more complex so that the even more complex billing proclivities can be managed by herds of people on both sides of the money:  people I pay to GET it – and people the payers pay to DENY it.  How dumb.    When my office overhead is ~ 60% .. (this is typical in primary care) .. it means that more than half of the money we collect doesn't go to health care.  Makes one think about other crazy paradigms of care delivery – eh?   Maybe not so crazy.

The French Smart card is just an example of how a system just works as it should.  Sure – Michael Moore's movie is a bit over the top – but he's right. 
Of course he's right.  I've been a member of PNHP for nearly two decades now (I hosted the website in my attic for its first few years of existence) and though I've been less involved in the organization lately – I remain convinced that we need to fix this problem with a single-payer solution.   Intelligent use of technology – with patients at the center – will also help us to spend less time on the administrative chores – and more time on the important work of making thoughtful, evidence-based decisions with our patients. 

Yes – WITH our patients – not for them:

In the 1970s … studies began to show that patients with chronic conditions who are active in their own care have much better health outcomes. And yet … doctors and patients are still stuck in … "Marcus Welby mode" — with the omniscient, paternalistic doctor ministering to the passive, nodding patient.
(From this Washington Post article)

In Health IT – we need to practice precisely the same way:  Understand best practice, educate our customer, and develop our skills, tools and partnerships in a manner that will help support them to the best of our ability.  This is too important to treat it like a business.  This is a profession – guided by important principles of equity, fairness, and benevolence.  

Tags: HealthIT Open Source