Sep 27, 2017

Medical Considerations Behind Emotional Support Dogs

By James G Baker, MD
Member, TMA Council on Science and Public Health

If a patient asks you to sign a letter supporting his emotional support dog, should you do it?

For a canine to be designated as someone’s emotional support dog, the person seeking such an animal must have a note from a physician or other medical professional stating that (1) the patient does have a psychiatric disability, and (2) the emotional support animal provides a benefit for the patient beyond the simple need for companionship. The most common reason for the letter request is that emotional support dogs legally are viewed as a “reasonable accommodation” in apartments that have a “no pets” rule.

The idea of using a dog as emotional support would seem to make perfect sense. After all, who wouldn’t benefit from having a four-legged friend at his or her side? Assuming you are the patient has a disability, here are a couple of considerations when assessing the benefit to your patients.

First, while there is good research showing the benefits of service assistance dogs for people with physical disabilities, there is little evidence for the use of service assistance dogs, let alone emotional support dogs, in mental illness. How are service dogs and emotional support dogs different? Service dogs are trained intensively by professionals for many months to perform specific tasks for people with disabilities. For example, service dogs are trained to open doors and turn on lights for people with physical disabilities. They might serve as ears for the hearing-impaired or as eyes for the visually impaired. Service dogs can also be trained as skilled companions for people with intellectual disabilities or mental illness. By contrast, an emotional support dog is not trained to do any specific tasks related to a disability, but rather provides a therapeutic benefit to its owner through companionship.

Second, the lack of specific training requirements for an emotional support dog is problematic. Hopefully the patient’s dog is friendly, calm, and without unexpected behaviors, especially in public. But due to the lack of training, an emotional support dog may bark, act aggressively if it feels threatened, or be intrusive of others in public. By contrast, a service dog is trained to ignore distractions and cause minimal imposition to its surroundings. At very least, an emotional support dog should have formal obedience training sufficient to obtain a canine good-citizen certificate, but longer-term obedience training would be even better. Ideally, the dog would be a skilled-companion service dog trained in skills and tasks to help mitigate the patient’s specific disability.

Hopefully in the not-too-distant future there will be an evidence basis for recommending emotional support dogs for people living with mental health challenges. For example, the Department of Veterans Affairs is participating in a three-year study to compare service dogs and emotional dogs in the management of post-traumatic stress disorders. But until there is evidence to support the use of dogs, it is important to steer patients towards treatments that show evidence-based benefit for their specific challenges.

Peaberry, Dr. Baker's current
assistance pup-in-training.
Dr. Baker and his wife, Janet, serve as volunteer puppy-raisers for Canine Companions for Independence, a nonprofit organization that enhances the lives of people with disabilities by providing highly trained assistance dogs at no charge to the recipient. Dr. Baker also is associate chair of clinical integration and services in the Department of Psychiatry at Dell Medical School and systems chief medical officer at Integral Care, the public mental health authority for Travis County.

Sep 8, 2017

Physicians Can Help Stop Teen Drug and Alcohol Abuse

By James Baker, MD
Austin Psychiatrist
Member, TMA Council on Science and Public Health

It takes a community to prevent adolescent substance abuse, and physicians can play an important part in that community effort.

While parents are the most important role models for their children, as physicians, our goal should be to help delay the age when teens first use alcohol or drugs. In addition to all of the problems related to underage drinking — sexual assaults, accidents, poor school performance — research suggests that teens who start drinking early are much more likely to have an alcohol use disorder as adults.

How can physicians help?

Prevention requires a community focus on the many risk factors that often lead to early drinking and drug use. Physicians can be mindful of these factors when they see teens in their practice. Here are some things physicians can look for and, when present, encourage teens and their parents to get help for:
  • Family history of drug or alcohol use,
  • Family problems or disruptions,
  • Low motivation at school,
  • Behavior problems at school, and
  • Friendships with other teens with problem behaviors.
When these issues are present, doctors can encourage interventions to address them. For example, poor school performance warrants an evaluation for undiagnosed learning disorders. Family issues warrant an evaluation to see if family therapy is recommended. Motivation issues and behavior problems might indicate an underlying mood or other emerging psychiatric disorder. The local community mental health center is a good resource for all of these problems.

In addition, physicians can adopt the practice of routinely screening for alcohol and drug abuse in their young patients. Screening for depression, anxiety, stress disorders, and substance use ought to be just as routine as taking vital signs. One possible screening tool is CRAFFT. CRAFFT is just six questions shown to be effective in assessing whether a referral is indicated for a longer evaluation of alcohol or drug use. CRAFFT stands for:

Car (Have you been in a car with a driver — including yourself — on drugs or alcohol?),
Relax (Do you use drugs/alcohol to relax?),
Alone (Do you use drugs/alcohol while alone?),
Forget (Do you forget things while on drugs/alcohol?),
Friends (Are your friends concerned about your drugs/alcohol use?), and
Trouble (Have you gotten into trouble while on drugs/alcohol?).

Finally, because they are community leaders, physicians can encourage the entire community — parents, teachers, coaches, and religious and civic leaders — to give children the same messages discouraging alcohol and drug abuse, starting very early in childhood.

We can help teens — and their families — avoid long-lasting consequences of alcohol and drug use through a collective and consistent message, universal screening, and early and aggressive intervention.

Dr. Baker is associate chair of Clinical Integration and Services in the Department of Psychiatry at Dell Medical School and systems chief medical officer at Austin Travis County Integral Care.

Aug 17, 2017

Physician Viewpoint: Physician, Heal Thyself (with Help)

By Dr. Manish Naik

This article was originally posted on Austin Regional Clinic's leadership blog.

Doctors see firsthand the toll that today’s increasingly stressful society takes on patients: Engineers, office managers, teachers, you name it. Work demands have increased, as has multitasking. Demands outside the workplace add additional stress. Often parents chauffeuring children to multiple activities must also care for aging parents with increasing needs. Electronic devices, always in hand or close by, command our attention (because of work or personal needs), sometimes simultaneously. Finding a moment to catch one’s breath is as difficult as getting enough sleep.

Doctors also see stress mounting in the mirror. We struggle to keep an even keel while facing growing demands above and beyond caring for our patients. Study after study, survey after survey shows that increasing responsibilities – many taking physicians’ time away from personal interaction with patients – are taking away some of the joy in a profession to which we have dedicated our lives and our hearts.

Overcoming ‘Paperwork’ Fatigue

I wouldn’t call it “burnout.” That term suggests giving up or throwing in the towel. It’s more about having the resiliency to meet today’s challenges. Mostly, we’re frustrated and exhausted by administrative and clerical tasks, both in electronic and paper form, pulling us away from our patients. Even ownership of the physician clinical note is tainted by the regulatory burdens related to coding and discrete data documentation for analytics and quality measurements.

The challenge of resiliency needs to be a priority not only for physicians, but the healthcare systems to which they belong. There’s no single cause, but a lot of it is epitomized by the electronic medical record (EMR), particularly among seasoned physicians moving well beyond the paper records they started with at the beginning of their careers.

A December 2016 American Medical Association study starkly spotlighted the problem: for every hour of face-to-face time devoted to patients, physicians spent almost two hours on EMRs and other clerical work. With patient loads jumping and individual patient needs rising, physicians need better tools to maintain their resiliency.

Austin Regional Clinic has recognized the challenge of physician resiliency and is trying to address it on several fronts. For example, we have a team working full-time on optimizing EMR efficiency.  Can we cut the number of computer clicks for each task? Something as simple as ordering a prescription – a task physicians used to do by scribbling a note on a paper pad – can take dozens of clicks while searching through lists of medications, dosages and more.

We’re creating common order sets (called “smart-sets”), preference lists with repetitive orders and medications, and other shortcuts in our EMR to reduce the number of clicks required for common tasks. We also have a team of “specialists” dedicated to meet with physicians onsite at their clinics to help optimize individual EMR workflows and preferences.

EMR vendors have not been able to place the focus needed on improving the user interface, largely due to the burdens of meeting ever-growing regulatory demands for national programs such as Meaningful Use and MACRA (Medicare Access and CHIP Reauthorization Act).  However, the software’s interface with physicians should be improved, and ARC is committed to doing all it can.

Another way to lighten physicians’ clerical loads: scribes who can join physicians during patient visits and assist with EMR documentation, ordering and other electronic clerical tasks in real time. ARC had a successful pilot program and is currently offering scribes to additional physicians who may be interested. We also have advanced practice clinicians, acting as “extenders” to physicians, performing and documenting routine exams such as Medicare wellness check-ups.

Meanwhile, savvy professionals in many fields are turning to mindfulness, meditation and other “me time” activities to reduce stress. They also can and should turn to each other on this issue, viewing it as a mentoring topic. A very effective antidote for decreased resiliency is the professional, day-to-day interaction between physicians, like discussing diagnostic and treatment challenges or the joys of those successes. Time challenges have led to fewer of those interactions. ARC is working on some upcoming formal programs to provide physicians with some of these stress-reducing tools.

Healthcare systems and medical groups should partner with physicians to enhance their resiliency. They have an obligation to do what makes sense to keep physicians enthused and performing at the highest level. The best place to start? Allow physicians to do more of what they do best – heal patients – and less of what others can do – computerized paperwork and administrative tasks.

Manish Naik, MD, is a practicing internist at Austin Regional Clinic (ARC) as well as ARC’s Assistant Chief of Internal Medicine, ARC Chief Medical Information Officer, and ARC’s Electronic Medical Records (EMR) Physician Champion.

Jul 31, 2017

The Missing Link: Patient Responsibility for Health Records

By Joseph H. Schneider, MD, MBA
Department of Pediatrics, University of Texas Southwestern

This article was originally published at Hayes Management Consulting.

Sitting on the exam table before a routine procedure, I listened as the nurse reviewed my medical information. She checked my name, address, and birthday. All was well until she said “..and you are allergic to Wellbutrin, Toradol, Darvon and sulfa”. My brain sprang to attention as she continued reading that I had shoulder repair and coronary bypass procedures, that my weight was down 50 kilograms and that my father was alive. It was very detailed.

It was also all very wrong. I have no medication allergies, nor have I had any of the named surgeries. My weight hasn’t changed. And my father passed away in the 1980s.

What happened? My record was mixed up with someone else’s and my health care information was now seriously incorrect. Fortunately, as a CMIO, I was able to get the 120 pages of my record rapidly corrected.

But what if I was an average person, without the influence to gain quick access and to make corrections? What if I hadn’t been having the procedure? The incorrect data could have led to dangerous consequences.

Unfortunately, that is the reality for a significant number of individuals today. Patients are misidentified 10 percent of the time, resulting in an inappropriate record merger or a duplicate record. Nine percent of these misidentifications result in medical errors. That’s about one percent of all interactions resulting in errors.  According to one study, a significant number of patients are harmed or die each year from identity errors.[1]

I used to believe that patient records were best managed by healthcare organizations and physician offices. But after over 20 years in healthcare informatics, my view has changed.  Because patients travel, relocate, transition from a pediatrician, get care in multiple locations, change physicians because of insurance, and many other things, I’ve concluded that it is unrealistic to expect that these multiple medical organizations can get the records of all patients correct all of the time. Even with a national patient identifier, this wouldn’t be possible.  And if we can’t achieve extremely high reliability in the accuracy of our records, then a different solution is needed.

The different solution?  Create a system that supports the right and the ability of individuals to be responsible for their own healthcare record and even to have control over it, with help as needed.  With respect to interoperability, this means that some patients may even control what information is exchanged because they control their own records.  This would augment, not replace, traditional physician/hospital controlled records for those patients who could not handle these responsibilities.  The personal involvement that this engenders might be the most important step in getting accurate health information to the right place at the right time.

Getting to where patients can manage and control their records

Creating a system that supports patient-controlled health records seems challenging. Here are three things that we could be doing now to get started:

Step 1. Let’s encourage verification of healthcare data by patients

When visiting a doctor or healthcare institution, we should encourage patients to view their record, not just have it read to them.  If there are errors, let’s correct them on the spot, wherever possible.   Where there is disagreement (e.g., “I’m allergic” vs. “That’s not an allergy”), let’s either resolve this or record it so it is visible when the record is viewed in the future, including if the record is shared for care elsewhere.

If there is something that can’t be done in the visit, (e.g., the extensive errors in my case), let’s make it easy for everyone to get their records corrected. Too often, the request to review records takes an eternity and the records are delivered in a way that makes it near-impossible to find and correct errors.

Open Notes and some types of patient portals are a start towards this, but patients need encouragement.  For those who need help in this (e.g., my 93-year-old mother who recently received a drug to which she was allergic), let’s find ways to provide that help.  An example would be extending the role of care coordinators to give them the responsibility of assisting patients with their record review.

Step 2. Let’s develop the tools to enable patient-managed records

Patients with complex problems or their caregivers may track their medical data using a word processor, spreadsheet or a commercial personal health record. They often bring this to hospitals and physician offices, but usually there is no easy way to upload this information into the clinician’s EMR. On discharge or the end of their visit, these records are rarely updated automatically. These patients need better easy-to-use tools that our EMRs can use to easily upload and download data.

Let’s start by asking EMR vendors to incorporate the Blue Button. EMRs that offer the Blue Button use this for downloading health records to patients. They can then share them with other doctors and caregivers, check to make sure the information is accurate and complete, have medical information available in an emergency or plug the information into mobile apps and tools. The Veterans Administration is one of the first organizations to adopt the Blue Button. Let’s work to have all systems adopt this.

But not every patient wants to maintain their own records.  For those who want to use a patient portal, they often are faced with having a portal for every place where they received care.  This is absolutely NOT patient-centered.  Let’s request our EMR vendors to open their EMR patient portals so that a patient can designate a “master” portal for health information that other systems would feed data to and use as a source for accurate patient information.

Let’s also request notifications to patients from EMRs any time that their records are changed. Many organizations now send us confirmations of activity electronically.  Why can’t this be a basic requirement for healthcare records?

Developing tools for patient-managed records raises lots of questions such as how to deal with individuals who can’t handle their own records, how to ensure accurate or necessary information isn’t suppressed, and handling patients who incorrectly represent their history. All of these have answers, but we need true national standards or we will recreate the electronic silos of Meaningful Use.  So let’s work together as patients, clinical and informatics professionals to plan how this new electronic ecosystem should work.  Let’s also build in research capabilities for usability and safety in addition to clinical studies[2]  so that every patient’s daily interactions with these tools contributes to our knowledge, with their consent.

Step 3. Let’s educate everyone on the importance of patient-managed records

Everyone – patients, doctors, nurses, organizations – needs education that patients have a vested interest in the accuracy of their own health records and, with some education and the right tools, can be qualified to manage them. We need to increase the awareness of the importance of patient involvement.

The move toward consumerism in healthcare has already started getting patients to take more responsibility for the financial aspects of their care.  Let’s encourage the same mindset when it comes to medical records.

We can begin by working with medical and nursing societies and patient/consumer organizations to convince clinicians and healthcare leaders that patients actually can be responsible for managing their own records.

The process has begun

Although implementation of patient maintained records may seem like a distant concept, it is not as far-fetched as it might appear.

In the UK, a personal health record company called Patients Know Best (PKB) provides patients with secure online access to manage their personal medical records. PKB is integrated into the UK’s National Health Service[3].

Here in the U. S., there are numerous personal health records efforts.  Few, if any, are in widespread use, in part due to the challenges of maintaining them.  Individual health systems such as Scripps Research Institute[4] are working on changing this.

Summary

We have spent over $30 billion on making our healthcare system electronic, but have little in place for patients who want to take care of their own records. It’s time we focused on closing this missing link.

Dr. Schneider is a retired informatician but still practices newborn medicine in Dallas.  He can be reached at drjoes1tx@gmail.com.


[1] Why Patient Matching Is a Challenge: Research on Master Patient Index (MPI) Data Discrepancies in Key Identifying Fields; Just B et al. Perspectives in Health Information Management, AHIMA Foundation, Spring 2016.
[2] https://www.wsj.com/articles/smartphones-open-a-new-world-for-medical-researchers-1498442821; Wallace C.  Wall Street Journal, June 25, 2017.
[3] Patients Know Best: A Changemaker Health Case Study; Strickland M. March 21, 2017.
[4] The Smart-Medicine Solution to the Health-Care Crisis; Topol E. Wall Street Journal (subscription required), July 7, 2017


For more information on electronic health records, download the Hayes Management Consulting roadmap, How to Save Your EHR: 6 Steps to Holistic Optimization.
Hayes_ROADMAP_Save_EHR_Holistic_Optimization_TN_2.jpg

Jun 11, 2017

Texans on the Dias

(CHICAGO) As usual at meetings of the American Medical Association House of Delegates, Texans from the youngest to the most experience are playing a lead role in the 2017 summer meeting.

Former TMA President Sue Bailey, MD, of Fort Worth was reelected to her third term as speaker of the house. Pediatrician Gary Floyd, MD, a member of the TMA Board of Trustees, is completing a two-year stint on the Reference Committee on AMA Finance and Governance. Ray Callas, MD, an anesthesiologist from Beaumont, is serving on the Reference Committee on Legislation; and Jerome Jeevarajan, a student at the University of Texas Southwestern Medical School in Dallas, served on the Reference Committee on Medical Education.

Clockwise from top left: Dr. Floyd, Dr. Bailey
Mr. Jeevarajan, and Dr. Callas

The Texas Delegation to the AMA is working hard to ensure a victory on Tuesday, when John Carlo, MD, of Dallas faces off against three other candidates for two seats on the AMA Council on Science and Public Health.

Some other election results already have come in. Former TMA President Bob Gunby, MD, was elected vice chair of the Organization of State Medical Association Presidents. Plastic surgeon Susan Pike, MD, was elected to the governing board of the AMA's Integrated Physician Practice Section. Dr. Pike is the director of the Cosmetic Surgery Center at Baylor Scott & White's Round Rock campus. Mr. Jeevarajan was elected medical student delegate to the AMA House of Delegates,  and these Texas students were elected to AMA Medical Student Section Region 3 leadership positions:

  • Emily Dewar, chair, UT Houston McGovern School of Medicine;
  • Aaron Wolbrueck, secretary, Texas College of Osteopathic Medicine; and
  • Jason Meschin, community service chair, Texas A&M College of Medicine.

Video: Legislative Session Victories Snapshot

Watch this TMA Legislative News Hotline video summary of a few of the biggest issues addressed in the regular session of the 85th Texas Legislature, which concluded a bit more than a week ago. TMA advocacy team members Dan Finch, Troy Alexander, Michelle Romero, and Clayton Stewart share notes on some top legislative priorities lawmakers answered this session: A surprise-billing solution; new law to define and regulate telemedicine; a prevention initiative passed to keep Texans safe; and how Medicaid funding for the next two years could affect patients and physicians. We also add an update on a priority bill signed this week, and shine a light on the future, when lawmakers will return to Austin. All of that, and a special message from TMA’s Advocacy Vice President Darren Whitehurst, are featured in this week’s episode.



Tune in next week, when Hotline will delve deeper into issues passed this session, beginning with the budget, mental health, and women’s health — as well as  legislation regulating use of maintenance of certification.

May 23, 2017

MOC - It's All About the $$ - Yes to SB 1148

Oppose Vendor Greed That Isn’t Shown
to Improve Quality

Senate Bill 1148, scheduled for debate on the floor of the Texas House of Representatives today, clearly states that hospitals and health plans cannot use maintenance of certification (MOC) to differentiate among physicians for payment, contracting, or credentialing. The bill prohibits the state from using MOC as a requirement for state licensure or renewal. It would, however, allow MOC requirements if facilities or teaching faculty need them for specialty designation or accreditation.

The bill's author is Sen. Dawn Buckingham, MD (R-Lakeway). As a practicing opthalmologist, Senator Buckingham knows a thing or two about the bureaucratic hassles that get in the way of physicians taking care of their patients.

SB 1148 stops the discrimination against physicians who elect to skip the burdensome, often-irrelevant, monopolistic MOC process. MOC claims to ensure quality, but in reality the components tested often are not applicable to medical practices. It’s a revenue generator for testing companies. So if you are wondering why the certifying boards are fighting so hard against SB 1148, remember, it’s all about the money.

"It's a money-making operation," says Texas Medical Association President Carlos J. Cardenas, MD.

In 2014, MOC generated $27 million for the American Board of Internal Medicine (ABIM) (48 percent of total certification testing revenue, 44 percent of total revenue). And, until the backlash really started to hit in 2015, MOC fees have been a steadily rising source of income for ABIM.



And this is personal for the organization. ABIM’s reported staff expenses (salaries, benefits, and other) increased 53 percent from 2009 to 2016, to $34.1 million. In 2015, ABIM spent $30 million on salaries and benefits and only $6.3 million on actually administering MOC.



As of 2016, the ABIM’s staff retirement plan net assets were $27.1 million, double the organization’s $13.6 million total net assets.

Mandatory MOC amounts to unnecessary overregulation of medicine. There is no proof at all that MOC improves patient care. Two peer-reviewed studies published in the Dec. 20, 2014, issue of the Journal of the American Medical Association compared physicians who had and had not completed MOC. Those studies found no differences in patient outcomes or in the number of hospitalizations that could have been prevented due to better quality of outpatient care.

Almost all other published studies evaluate initial board certification, not recertification or MOC, and the rigorous requirements for initial certification should not be equated with the busywork required for MOC every two years.

SB 1148 does NOT eliminate the state’s strict standards for physicians to earn continuing medical education credits to maintain our licenses. It does NOT change the status of, negate, or in any way minimize the initial board certification that physicians work so hard to achieve.

And if you haven't done it yet, please use the TMA Grassroots Action Center to ask your state representative to vote “YES” on SB 1148

May 11, 2017

Mandating MOC to practice medicine is an appalling overstep of nonexistent authority

By Carlos J. Cardenas, MD
TMA President

This article was originally published at KevinMD.com.

Maintenance of certification (MOC) for something as significant as the practice of medicine seems like a harmless enough idea. But for physicians across the country who dedicate thousands of hours to study, earn licensure, achieve board certification, and practice medicine, MOC is not only unnecessary but also a resource-consuming mandate that does nothing to improve patient outcomes and quality of care.

According to the American Board of Medical Specialty’s (ABMS’) own website: “Board certification is a voluntary process, and one that is very different from medical licensure … Board certification demonstrates a physician’s exceptional expertise in a particular specialty and/or subspecialty of medical practice.” In other words, physicians who pursue board certification self-identify as professionals committed to ongoing learning and subject-matter mastery. The vast majority of Texas physicians willingly pursue and obtain their initial certification for just that reason.

ABMS introduced MOC in the past 20 years, granting a lifetime certification to physicians board certified at the time of its creation. The rationale for the arbitrary “grandfathering” date is murky and ambiguous at best.

In the past 12 months, several states have passed laws specifically disallowing reliance on MOC for credentialing, payment, and contracting. More are considering legislation this year. Serendipitously, Oklahoma had success with Senate Bill 1148 — the same bill number for legislation courageously authored by Texas State Sen. Dawn Buckingham, MD, a physician in the Austin area. Texas’ SB 1148 prohibits the state from using MOC as a requirement for state licensure or renewal. It prohibits hospitals and insurance companies from relying on MOC for credentialing or contracting. That bill is working its way through the Texas Legislature this week.

The Medical Credentialing System in 2014 reported revenues of more than $2.5 billion — $1 billion of which is attributed to ABMS entities alone. The American Board of Internal Medicine (ABIM) is the largest of ABMS’ credentialing agencies and is responsible for credentialing one-quarter of all physicians.

Drilling down further into those numbers is eye-opening. ABIM reports $58 million in revenue for 2015, nearly $27 million of which came from MOC fees. With $30 million spent on salaries and benefits that year and only $6.3 million on actually administering the MOC, one could easily draw the conclusion that the push for MOC is nothing more than self-serving largesse. Well, that and the luxury three-bedroom condominium purchased in downtown Philadelphia in December 2007. The money these boards collect and spend — on expenses like first-class, cross-country airfare for their staff — just adds to physicians’ ire over MOC mandates.

In fact, some specialty boards have emerged as a direct result of the revenue-generating opportunities MOC offers. Forty-two medical specialty boards now exist to conduct MOC courses. Forty-two. Providing employment for test proctors does nothing to improve patient care and outcomes. “Do no harm” is not just an oath to be sworn by physicians. It is also a standard to which MOC should be held. If it truly is voluntary, as ABMS asserts, stop punishing physicians who elect not to pursue it.

From the extraordinary dedication physicians demonstrate by initially achieving board certification, to meeting and exceeding continuing medical education requirements, to continuously putting patient care first and foremost, mandating MOC to practice medicine is an appalling overstep of nonexistent authority. Not only that, it is driving experienced, caring physicians from practice.

Texas physicians are determined to end this over-testing tyranny and ensure Texas remains a “right to care” state.