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The CMG Voice

Using Your Smartphone for Symptom Tracking

Posted Thursday, November 7, 2019 by Carl-Erich Kruse

You may have already read some of our previous posts regarding the use of smartphones and wearable devices in monitoring patient health. The technology remains rather new, so continues to evolve and improve. One overall goal is trying to fit the technology into a person’s overall healthcare. A recent paper out of the UK demonstrates the utility of our phones tracking symptoms for specific conditions: specifically those of rheumatoid arthritis. And it provides a positive outlook for long-term symptom tracking for chronic conditions.

One hurdle providers frequently contend with is being forced to rely exclusively on a patient’s self reporting of symptoms between visits. Sometimes these visits come over several months. And it goes without saying that patients’ memories are imperfect. Contemporaneous reports are far more reliable and create a nearly objective set of data for providers to look back on.

Physicians at Manchester University in England worked with developers to create an app for patients to track their subjective arthritis symptoms. The app passively tracks weather data from the location of the smartphone, and the patients’ movement through an accelerometer that is already embedded in the phone. The data is then combined more or less contemporaneously, and automatically loaded into the patient’s chart. The patients providers, then, could take the data and correlate the patients symptoms with weather patterns over time. The app is called, appropriately, Cloudy with a Chance of Pain.

Outside of the world of arthritis, patients, providers, can use a model similar to this to track chronic patient conditions that should lead to less misdiagnoses, or delays in diagnosis. We can imagine a world where, for example, heart disease patients can report symptoms that are then matched with activity monitors in wearables or smartphones. The patients’ cardiologist or primary care provider can then review those notes in the chart at the patient’s next visit. Ideally, this will help catch pathology before it gets any more serious.

Read the study here: Cloudy with a Chance of Pain: Engagement and Subsequent Attrition of Daily Data Entry in a Smartphone Pilot Study Tracking Weather, Disease Severity, and Physical Activity in Patients With Rheumatoid Arthritis

Read our previous coverage of wearable technology here and here

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Causation Issues in Cases Involving a Delay in Diagnosis

Posted Monday, November 4, 2019 by Gene Moen

In most cases involving a delay in diagnosis, a major problem is that or proving causation. In all medical malpractice cases, the burden is on the claimant to prove (1) negligence and (2) what injury was caused by the negligence (this is the causation issue).

A classic example is a case in which a diagnosis of cancer is not initially made, even when there are signs and symptoms to suggest the diagnosis. The mistake leading to the delay may be that of a physician who doesn’t misses the significance of the signs and symptoms, a radiologist who misses a key finding, a pathologist who misreads the pathology slides, etc. In some cases a defendant may retrospectively acknowledge negligence, but still contend that the delay did not cause provable injury.

In cancer cases, depending on the type of cancer, causation may be provable by experts who can explain the growth or pattern of the cancer cells in order to work backward from the point of diagnosis to the point when the diagnosis should have been made. That is an easier burden to meet when it is a more common cancer where there are numerous published studies about the cancer, such as breast cancer. But for many less common cancers, there is a dearth of published studies or data that would allow that kind of analysis.

Washington recognizes “loss of a chance of a better outcome” as a cause of action. So even if it is not possible to prove that a particular bad outcome is more likely than not caused by the delay, it may be possible to prove that the chance of a better outcome was reduced.

An example is where a delay means a cancer patient went from a 45% chance of five-year recovery to a 15% chance. The problem is that the law requires that the “loss of a chance” be quantifiable, and usually that evidence can only be provided by medical experts. Many of them are loathe to speculate about “what if” questions, unless there is (as in the breast cancer example) a lot of published data on which to base an opinion.

A variation on the issue of causation arises in cases where the evidence needed to prove causation isn’t available because the defendant was negligent. A classic example is where the patient has a bad outcome from a fractured leg that wasn’t x-rayed in an emergency department. The consulting expert may not be able to say how much worse the fracture became when the patient was weight-bearing over time, because the expert can’t compare the diagnosed fracture with how it would have appeared in the missed x-ray.

That same problem occurs in cases where a diagnostic or screening test, like a mammogram or colonoscopy, was not done when it should have been, thus depriving the expert of the date needed to express an opinion on causation when the cancer is not diagnosed on a timely basis.

It is often difficult to explain this to a potential client who has had a poor outcome and thinks the negligence is clear. To be successful in a malpractice case, one has to establish the link between that bad outcome and the negligent care, i.e., that the poor outcome was caused by the negligence.

Interestingly, physicians also are confused by this issue. When physicians evaluate whether there was bad care, such as peer review of a physician’s practice, they focus on whether the bad care had the potential to cause injury to a patient, whether or not such injury actually occurred.

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Medical records do not always tell the (whole) truth

Posted Monday, October 28, 2019 by Gene Moen

For those of us who review electronic medical records day after day, there is always a concern of whether they are accurate. In the “old days” when a doctor wrote down his observations and actions upon examining a patient, we assumed the information in the record was probably complete and correct. After all, why would the doctor or nurse take the time to write it down if it didn’t happen? An old saying is that “if it’s not documented, it wasn’t done.”

Now, when you see a lengthy list of all the items covered in “review of systems,” and the patient tells you the exam only took less than a minute, there seems to be a discrepancy. With the advent of electronic medical records, that assumption of accuracy no longer holds. With pull-down menus and pre-programmed paragraphs, the electronic system allows a doctor to simply click a button to record what happened, and therefore what would be billed.

A recent study published in the JAMA Network in September of 2019 found that nearly half of the physical exam findings documented in the electronic record never happened. A team of observers noted what was actually done in numerous exams and then compared that with the electronic record.

The financial incentives for a hospital to bill for more complete assessments and exams may be a partial explanation. The fact is that the electronic record is a billing document, and often not a true reflection of what the physician has done. There are also time pressures on providers to record, for example, a full neurological exam when there was only a quick assessment.

The dangers in this practice are obvious. For example, the electronic record notes that a doctor did a complete review of systems and that the patient was neurologically intact. When there are focal neurological signs the next day, the provider assumes this is a new development and may take different actions than if it was known the symptoms were there 24 hours earlier.

While the old saying was “if it’s not documented, it wasn’t done”, perhaps a new one is more accurate: “if it is documented, it probably wasn’t done”.

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Doctors may be making house calls again (with a technological twist, of course)

Posted Thursday, October 24, 2019 by Carl-Erich Kruse

Though many of us have never seen a doctor on a house call, we all likely think fondly of the idea. A kindly doctor, who takes his or her time, focuses on what matters most: the patient. The scenes in shows like Marcus Welby, MD, are ones with no shots of frantic frustrated calls with insurers, or of overworked providers juggling 20+ patients with administrative responsibilities. That era is long gone, if it ever existed. Or is it?

Recent investments in startups focusing on house call companies portends a potential return of the kindly doctor with a black bag. Except in the new future the doctor will be capitalizing on technology to speed many of the time consuming administrative tasks. We, as a society, have grown increasingly accustomed to food, groceries, and shopping being brought to us; perhaps the leap to bringing a doctor to our door is not such a long one, then.

The appeal, though, is not just nostalgia. Some of the arguments that have brought investment to these startups include the obvious convenience factor, but one startup argues that its service has reduced urgent care and emergency department visits by as much as 71%, and saved a half a million dollars in overall healthcare costs.

For purposes of this blog, what does this mean for the quality of care? Ideally providers get a better sense of a patient’s symptoms and complaints while they can see them in their natural environment. That visit may allow more opportunity to connect with patients, again, comfortable in their own home. Certainly, patients will have fewer “no shows” in this scenario, and perhaps even some who are uncomfortable with doctors offices may be more willing to bring one into their own home.

On the other hand, doctors who see patients coming to them are commonly overworked and overstressed; this model is asking the doctors to commute (in traffic!) from patient to patient. How many patients will a provider be expected to see in a day? Who are the providers these startups are hiring to provide care? And how much continuity of care will there really be?

Call us cynics, but the idea may sound better than its actual execution. Perhaps larger, more established medical care systems will dip their toes further into the pool, and the door-to-door health care delivery model will benefit from the solid foundations of established health systems.

It is early to tell if this idea will take hold and whether it will actually improve delivery of health care.

Read the original article here: Heal, a medical house calls startup, acquires Doctors on Call

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Controversy Over Which Comes First In Sepsis: Antibiotics or Blood Culture.

Posted Monday, October 21, 2019 by Gene Moen

An ongoing dilemma in treating patients with suspected sepsis has existed for years. In most cases, antibiotics is the first treatment, but which antibiotics should be given?

Some physicians, especially internal medicine or infectious disease specialists, want to know which organisms are causing the infection before deciding on which antibiotics to use. Using the wrong antibiotic can be a waste of time and delay proper treatment. Emergency room physicians, on the other hand, view prompt initiation of antimicrobial therapy as a critical determinant of survival.

The controversy was clouded by lack of knowledge of how quickly blood cultures lose their ability to grow organisms after antibiotics are given. A recent study done by Brigham and Women’s Hospital in Boston, described in Annals of Internal Medicine, found that if a doctor wants an accurate reading from sepsis patients’ blood cultures, starting antibiotics before you’ve drawn the blood samples can mean a significant reduction in accuracy of the cultures.

In general, the accuracy of blood cultures taken before antibiotic treatment were positive for specific pathogens in 31.4% of patients, compared with 19.4% when antibiotic treatment had already been started. One result of the study was the finding that even when cultures are performed very rapidly after antibiotics, they lose much of their diagnostic accuracy.

Of course, this has not resolved the ongoing controversy. Experts acknowledge the higher diagnostic value of blood cultures prior to giving antibiotics, but warn of “unintentional treatment delays” given the higher risk for death associated with a delay in treatment. Further studies are needed to determine which patients should have blood drawn before antimicrobial treatment and which can withstand the delays resulting from waiting for culture results. And clinicians are urged to emphasize the need for very rapid blood cultures so the delay before starting antibiotics is as short as possible.

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