Patient Care

How much privacy would you be willing to give up to maintain your independence? If you’re confused by the question, consider this Washington Post article discussing home-use medical devices that track behavior and vital signs in older adults to share with their doctors. Keeping tabs remotely could let an aging population stay in their homes longer.

From the piece:

Their medicine bottles will alert their doctor when they miss a dose. Pressure-sensing floor mats can sense when they have fallen or let caregivers know when a patient hasn’t showered for a while.
…

The devices often mean adding “sensor platforms in what have traditionally been protected spaces — your home, your office,” said Joseph Lorenzo Hall, [PhD,] chief technologist at the Center for Democracy and Technology. “Even something like a temperature sensor can be revealing . . . it can easily tell if you’re home.”

The effort also pushes traditional telemedicine, including video conferencing with your doctor, into a more intimate space.

But receiving such data from a patient can make it easier for doctors to monitor their health, said David Lindeman, [PhD,] a gerontologist and director for the Center for Technology and Aging. Also, he said, monitoring someone while they are in their natural environment rather than a clinical setting can also lead to more accurate diagnoses.

But with great data comes great responsibility to protect it. The article continues:

…widespread use of such technology can raise questions about whether patient’s personal details are being properly protected. More companies are entering the market that haven’t traditionally dealt with health information, said Hall of the Center for Democracy and Technology.

It is also unclear how data breach, security and other laws apply to the growing ecosystem of new devices, and how companies will set their own standards to protect the influx of data.

Previously: Eat a carrot and exercise – or your iBird dies and Research shows remote weight loss interventions equally effective as face-to-face coaching programs
Photo by Martin

As I’ve learned from dance and yoga teacher training, the gift of a good instructor lies not simply in how much knowledge she may possess or even how well she communicates it, but by how the student progresses as a result of their encounter. I thought of the teacher-student relationship when reading a post on KevinMD.com about a different sort of personal exchange – the one between a doctor and patient.

Cardiac electrophysiologist David Lee Scher, MD, outlines five ways physicians can better engage patients in their health so that medical advice dispensed during an office visit gets put to use in a patient’s everyday life for the long term. Tips include bedside-manner recommendations and effective use of technology as well as involving caregivers in a plan.

From the post:

2. Improve the patient and caregiver knowledge base. Much of patient behavior is driven by fear of the unknown. The purpose of each test and what it entails, the overall suggested plan, the possible diagnoses and their probabilities should all be touched upon. This need not be done in great detail but in a way in which the patient gets the overall picture. The reason for each medication prescribed and its most common potential side effects is something not always done, leaving patients with prescriptions and many questions even five minutes after leaving the office. A well-informed patient is the best patient.

And if you learn best through the combination of audio, visual and kinesthetic cues, check out this video of “The Cardiac Dance | The Spirals of Life,” which uses movement to explain the structure and function of a healthy or diseased heart.

Previously: “You belong here”: A recap of Stanford Medicine X, Why engaging patients in their own care benefits the health-care system, Personal essays highlight importance of cost-conscious medical decisions and Alan Greene talks about Medicine 2.0 and the future of doctor-patient communication

Children whose hearts stop while they are in the hospital need fast, well-coordinated resuscitation to give them the best chance of surviving their cardiac arrest. But because pediatric cardiac arrests are (fortunately) rare, pediatric physicians, nurses and other caregivers have few opportunities to experience a real response to this life-threatening emergency. And rehearsing what to do in educational settings outside the hospital may not give responders the chance to practice for unexpected problems that can arise in real life.

To solve this problem, a team at Lucile Packard Children’s Hospital Stanford implemented a new training approach. Lynda Knight, RN, MSN, the hospital’s pediatric resuscitation program educator, wanted to make sure that every person responding to emergency “codes” broadcast through the hospital when a patient’s heart stops – from attending physicians to security guards – had regular opportunities to practice working together. Knight and Deborah Franzon, MD, led a group that staged mock “codes” to simulate cardiac arrests in many locations throughout the hospital.

After the new training was implemented, the hospital’s survival rate for cardiac arrest patients jumped from 40 percent (a figure similar to the national average for children’s hospitals) to 60 percent. The findings were published this week in Critical Care Medicine.

From our press release about the study:

California hospitals have a new tool to help reduce maternal deaths. Today, the California Maternal Quality Care Collaborative released a toolkit for the treatment of preeclampsia, a pregnancy complication that can kill pregnant women and new mothers. Although, fortunately, few women die in California during pregnancy or birth, preeclampsia is among the leading causes of such deaths. Importantly, many deaths caused by this disease can be prevented if doctors know what to do.

Preeclampsia is characterized by high blood pressure in late pregnancy. It can escalate without warning to full-blown eclampsia, in which the woman experiences potentially deadly seizures. The only cure is delivery of the baby.

To help California hospitals handle this obstetric emergency, the CMQCC convened a task force that reviewed scientific literature on the disease. The task force, c0-led by Stanford’s Maurice Druzin, MD, developed a package of materials that includes care guidelines, such as identification of clinical “triggers” that require immediate evaluation; a compendium of relevant research on the disease; and educational materials for physicians and patients.

From the CMQCC’s announcement about the toolkit:

The primary aim of the Toolkit is to guide and support obstetrical providers, clinical staff, hospitals and healthcare organizations to develop methods within their facilities for timely recognition and an organized, swift response to preeclampsia. “Every hospital that provides obstetric care should have current guidelines on early recognition and response to preeclampsia,” says Dr. Druzin. An expert in the field, Dr. Druzin also served on a national committee that made recommendations to the American College of Obstetrics and Gynecology on how to diagnose and treat preeclampsia.

I spoke with Druzin when the toolkit was in development, and he stressed that sharing this information could prevent tragic outcomes for women and their families. “The good news is that with a modern treatment approach, most women and their babies can have safe, healthy outcomes,” he said.

Previously: Could exercise before and during early pregnancy lower risk of pre-eclampsia?
Photo by nanny snowflake

Centers for Disease Control Director Thomas Frieden, MD, wants more physicians to screen patients for risky alcohol consumption. From a public health viewpoint, this makes great sense. Even at levels of consumption well below what are common among people whom we think of as “alcoholic,” heavy drinking is a risk factor for injuries, accidents and assaults. Ethanol can also interact dangerously with medications a doctor may prescribe (e.g., ibuprofen and other pain relievers, sleeping pills).

But historically, three barriers have stood in the way of physicians screening more patients for risky drinking:

• Knowledge: There’s an old joke that using metal detectors to stop people from carrying guns (e.g., into schools) seems like a great idea up until the moment the detector goes off. If you screen for something, you’ll find it at least some of the time and be expected to respond. Some doctors don’t screen for risky drinking because they wouldn’t know what to do if they found it. Fortunately, over the past 20 years a brief counseling intervention has been developed and proven effective in multiple clinical trials. It’s an easily learnable technology that physicians find they can use across a range of patient health behaviors. But still, like any other clinical practice, it takes a long time to make these effective interventions a routine part of medical education and front line care

• Reimbursement: Primary care doctors typically have a lot of work to do with each patient in a short amount of time. It was therefore hard to persuade them for many years to address risky drinking by patients, particularly as it was not a compensated activity. That has now completely changed with the creation of billable codes for screening and brief intervention for heavy drinking, the provision of a problem drinking screening benefit in Medicare and the Affordable Care Act’s inclusion of these interventions as an essential preventative healthcare benefit.

• Psychological discomfort: The late Barry Rosen, MD, an outstanding addiction specialist and teacher, once listened to a psychiatric resident in my addiction medicine course say that asking patients about how much they drank was “too invasive, even rude.” Barry responded, “You think that’s invasive and rude when we are both part of the one profession that tells total strangers to ‘go into that examination room and take off all your clothes?’” Medical training should help doctors overcome their reticence by pointing out that if you can give a stranger a digital-rectal exam, draw their blood, tell them to take powerful medications and ask them about their safe sex practices, you can also ask them how much alcohol they drink.

In the future, as medicine becomes a team sport, doctors may oversee the care of risky drinking patients but not provide it directly themselves. One potential model of primary care is to have the team include a “habit specialist” who would use motivational counseling, behavioral change planning and monitoring to help patients with health behavior problems. This would certainly include heavy drinkers trying to cut consumption, but would include people attempting to lose weight, quit smoking and adhere to their diabetes care regimen. The VA is using psychologists in this role; Geisinger Health is using nurses. Both models seem a promising way to manage heavy alcohol consumption and other problematic health behaviors; it remains now to see whether they reduce the need for the acute care sufficiently for them to be economically viable across the entire health care system.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington. He can be followed on Twitter at @KeithNHumphreys.

Photo in featured entry box by jenny downing

Now, this is cool: A medical student practicing how to examine and diagnose patients wound up discovering a real, and serious, disease in an older man who was playing the role of patient. ABCNews.com has the story on how the student came to diagnose the man, who had no idea he had a health condition and was subsequently treated with surgery for his abdominal aortic aneurysm. “Jim’s life was saved by a University of Virginia medical student, no doubt about it,” his wife said.

Previously: Exploring the “fading art” of the physical exam and A journalist’s experience as a ‘standardized patient’

Clinical informatics, a field at the intersection of clinical medicine and information technology, has reached a new milestone: Physicians can now become board-certified in this medical sub-specialty. Christopher Longhurst, MD, who is the chief medical information officer at Lucile Packard Children’s Hospital Stanford and the leader of a new Stanford clinical informatics fellowship training program for physicians, talked with Scope about where this field has been and where it’s going.

First off, what exactly is clinical informatics?

In clinical informatics, we leverage information technology to improve outcomes for patients. Research has been done in this area since 1960s and 70s, but what’s different now is the ubiquitous nature of computing devices. Everybody has access to information and communications technologies. The majority of U.S. hospitals are implementing an electronic health record.

And yet electronic health records are not something most front-line doctors are really excited about – they can be seen as disruptive to the patient-care process. I really think we have yet to deliver on the promise of electronic health records. There’s a tremendous opportunity to use data in those records to build a health care system that can make personalized care recommendations and automatically learn from patients.

How is clinical informatics changing the way that medical discoveries are made?

The idea when I was in grad school was that randomized trials were the gold standard for medical evidence. But, increasingly, people are recognizing that this “level A” evidence is cost-prohibitive to generate. And the subjects are so narrowly selected that the results are not always generalizable. I know what medication to give a white male in his 50s because of high blood pressure, but what if I have a different kind of patient?

So a lot of people are advocating for a shift away from traditional trials, toward using enormous, anonymized data sets gleaned from existing electronic medical records. The idea is that you can make valid conclusions based on retrospective research if the data set is large enough.

That’s why we want to create a “patients like mine” button in every electronic health record that would essentially allow real-time comparative effectiveness studies. Then, if you’re treating a 40-year-old, half-Vietnamese, half-black woman for high blood pressure, you can instantly generate a similar cohort and see which medications have provided the best outcomes for those patients.

A “patients like mine” button would also help us start to understand what questions doctors ask. Today, we don’t always know what physicians’ information needs are. If we start to collect this meta-data, we can better focus randomized controlled trials so that they match doctors’ biggest questions.

How does Stanford lead the field?

Stanford is often considered the place where clinical informatics all started. The father of this field, Ted Shortliffe, MD, PhD, was a graduate student at Stanford when, in the 1970s, he wrote a software program called MYCIN to make decisions about prescribing antibiotics. MYCIN performed better at those decisions than your average internist. Shortliffe came back to Stanford in the early 80s and founded the division of medical informatics, now the Stanford Center for Biomedical Informatics Research, starting the Masters and PhD programs.

More recently, we have a really solid history of finding unique ways to use and study electronic medical records: For instance, we’ve provided automatic daily updates to parents whose infants are hospitalized in our neonatal intensive care unit, reduced unnecessary use of blood transfusions, assisted in selecting the appropriate IV fluid to give to kids and more, all under this one umbrella.

We have nine physicians who received the new board certification, placing us among the largest programs in the country.

Continue Reading »

A posse led by Stanford microbe sleuth and microbiologist David Relman, MD, has apprehended Staphylococcus aureus, one of the most notorious sources of serious infections, lurking in formerly unsuspected nasal hideaways. The discovery may explain why attempts to expunge S. aureus from the bodies of hospitalized patients being readied for surgery often meet with less than perfect results.

About one in three of us are persistent S. aureus carriers, and another third of us are occasional carriers. This bacterial shadow, which abounds on skin (especially the groin and armpits) and is quite at home in the nose, does us no harm most of the time. But if it gets into the bloodstream or internal organs, it can cause life-threatening problems such as sepsis, pneumonia and endocarditis (infection of heart valves). That makes S. aureus not such a good thing to be coated with if you’re about to have your skin punctured by a catheter or pierced by a scalpel.

This is exacerbated by the all-too-frequent presence, particularly in hospital settings, of S. aureus strains resistant to an entire family of antibiotics related to methicillin. In 2011, more than 80,000 severe methicillin-resistant S. aureus infections and more than 11,000 related deaths occurred in the U.S. alone, along with a much higher number of less-severe such infections.

In a study just published in Cell Host & Microbe, Relman – who pioneered the use of ultra-high-volume gene-sequencing techniques to sort out the thousands of species of microbes that communally inhabit our skin, orifices and innards – and his team used this method to show that mucosal sites way up high in our nose, where standard S. aureus-elimination techniques may not reach, can serve as reservoirs for S. aureus. That may, at least in part, explain why efforts to rid patients of this potentially nasty bug have so often fallen short of the mark, as I noted in my news release about the new findings:

Rigorous and somewhat tedious regimens for eliminating S. aureus residing on people’s skin or in their noses do exist, but it’s typically a matter of weeks or months before the bacteria repopulate those who are susceptible. The new study offers a possible reason why this is the case.

Previously: Cultivating the human microbiome, Anti-plaque bacteria: Coming soon to your toothpaste? and Eat a germ, fight an allergy
Photo by OakleyOriginals

If you followed the news on this year’s Stanford Medicine X conference, you might be familiar with the term ePatient: “empowered, engaged in your care, and equipped with knowledge about your condition,” as a Medicine X blog post describes. Later today, eight ePatient alumni will be joining in conversation via Google+ Hangout and Twitter to discuss features of the Medicine X ePatient program, eligibility requirements and how to apply for 2014.

Visit this page on the Medicine X blog to join the Hangout today at 5:30 PM Pacific time and use #MedX on Twitter to ask the panelists questions.

Previously: “You belong here”: A recap of Stanford Medicine X, Stanford Medicine X hosts Google+ Hangout tonight, Stanford Medicine X hosts live chat on Thursday with Bryan Vartabedian and Wendy Sue Swanson and ePatients discuss the “healing process” of IDEO Design Challenge at Medicine X

More from the Stanford emergency-response team in the Philippines: Two new Stanford Hospital videos – this one and the piece above – offer photos and video footage sent from those on the ground. After providing medical care to thousands of patients, the members of the Stanford Emergency Medicine Program for Emergency Response transitioned out of the disaster zone late last week and came home yesterday.

Previously: Post-typhoon Philippines: “It is all becoming real and sinking in”, Providing medical care to typhoon survivors in the Philippines and Stanford emergency-response team heads to the Philippines