Preparing for a Knee Replacement: A Checklist for the Family

You get a phone call from Mom; "Hi honey, I'm getting my knee replaced in 4 weeks, can you help Knee-replacement-rehabme?". Don't panic. We went through this and here are some tips to help you through this (disclaimer: this is not medical advice and your situation will always be different).  

Mayo Clinic has great overview of knee replacement (arthoplasty) here.

Pre-Surgery:
Book your airplane ticket now figuring you will need to be there at least one week after surgery. Try to find an airline that is forgiving in changing your ticket should you need to (SouthWest Airlines for example).

Since you are in charge, get a healthcare directive for the state your Mom resides. This allows you to make medical decisions if Mom cannot and gives you the right to talk to the physicians and other healthcare providers on behalf of the patient. Here’s a good place to start.  This is important because many times there are communication breakdowns between the doctor, the surgeon, physical therapists, etc. It shouldn’t be, but it happens. Be prepared. 

If you are curious about the surgeon and the hospital, you can access Medicare’s performance data here

Your mom will receive a pre-surgical packet of information. Read it and go over it with her. Put it in a “medical folder”. Make sure you both understand it. When in doubt, ask.  Don't be shy.

Get a notebook and write down the contact information for everyone on the medical side (and get their fax numbers). Make sure you have emergency contact information if something goes wrong. This notebook will also be used to create a daily log. The notebook is your best friend. Also get a calendar to record all the appointments and major tasks on it. 

Have copies of all the insurance and Medicare (if over 65) information. 

More things to do:
- Have transportation set up for your arrival if Mom does not have it: rental car, neighbor, car service, taxi, Uber, Lyft.
- Go grocery shopping and make sure you have enough to last 2-3 days after Mom comes home.
- Make sure there is a clear path for Mom to walk with walker after coming home. Remove throw rugs, runners and piles of books and magazines or anything else that might be an obstacle.
- Are there handrails for the stairs? Around the toilet? Toilet height extension? Bedpan / Urinal (if Dad)?
- Get a walker / cane  (put tennis balls on the front legs of the walker).
- Access to a fax machine (Fedex and UPS office centers have them). Many times the different parties involved cannot be reached and sending them a fax is the only way to get to them. Set up an inbound fax line like faxage.com ($3.50 / month). They can send an incoming fax right to your email box.

Still with me?  Let us continue.

- If Mom has pets, make sure they are taken care of during the hospital stay. Do you need lawn care / snow removal / house cleaning? Now is the time to set it up. Also put all those contacts in your notebook.
- Buy extra dressings for the surgical site. The hospital never seems to send enough home.
- Have a second complete set of bedding. Make sure they have clean bedding when they come home.
- Set up social and entertainment suited for your family member’s situation. Do you have the names of their friends? Books? Movies? Games to play?
- Follow up on everything. Just because someone says they will do something, doesn’t mean they will (hence the complete contact list, notebook and calendar). Be tenacious. The healthcare system is very frustrating most times.

At the Hospital (normally two days):
Become friends with the nursing staff. They will tell you how your mom is doing and give great suggestions. Find out when the doctors do rounds. Be there. Listen carefully to the physical therapists because they will be teaching what Mom needs to do to get better.

Keep your Mom's spirits up and give encouragement.  Have her talk to other family members and friends.  Bring some books or an iPad to watch a movie, or whatever else your Mom likes to do.

Make sure you have a copy of medications and understand what they are for and when and how long to take them. You may also want to talk to a pharmacist and make sure there are no adverse drug reactions. When our family member was at St. Joseph’s hospital in Atlanta, they didn’t do that and two of the drugs had the potential for a fatal interaction. Fortunately we caught it in time, but the medical team did not notice it.

Understand pain management thoroughly.  You may have opiates, Tylenol (acetaminophen) or Advil (ibuprofen) recommended. Make sure you know what to use, when.  Especially the opiates.

Go over the discharge papers carefully and understand what needs to be done when Mom goes home.

When leaving the hospital take the water bottle, emesis basin, washbasin, any lotions, creams, sundries and all supplies that came into your Mom's room. They could be useful at home. You paid for them. Take them home.

Back Home and Recovery:
The first week is the most critical. Your first order of priority is prevent infections. Wash your hands. A lot. Make sure the dressings are changed on schedule (aren’t you glad you picked up extras?).  Be on the lookout for anything that doesn’t look right at the surgical site. When in doubt call. You probably will be asked to take the patient’s temperature several times a day. This too is an early warning sign if it is too high.

That knee joint needs to be used especially during the first week so it does not freeze or limit range of motion. Having them lie in bed is not good for movement and also could lead to pneumonia or blood clots. Your packets will guide you on what to do. You should see a physical therapists on the first day home and 2-3 times a week, usually for an hour. Pay close attention to what they do and their instructions. Record this in your notebook and log all the exercises done.

Have meals at the table, not in bed.

Keep Mom's sprits up.  Play games, watch TV, whatever works for the two of you.  When she is ready, invite some friends over for a visit.

And finally, be very diligent on making sure the exercises are done (record them in the log book). Remember your Mom will be using a joint that just had surgery.  Being diligent becomes habit.  And that's a good thing.

Best of luck to you and your family.  Over 700,000 knee replacements are done every year.  You're in good company.

Do you have a personal experience or advice to share?  Leave a comment!


Business Case for FHIR and Argonaut: Patient Directed Post Acute Care

FHIR's purpose is an ambitious effort that defined healthcare standards and API's to accelerate ArgonautProject_logodevelopment of useful web-like applications from Electronic Health Records (EHR).  Project Argonaut is a private sector based initiative to build useful applications to drive adoption.

Applications for whom?  The current applications are heavily internal EHR focused among multiple institutions and EHR vendors.  

Although the industry talks about "patient centric" medicine, in reality that has as much relevance as "natural" has to foods you buy at the supermarket. Outside of a beauty contest called "patient satisfaction" there is not much in the field focusing on the patient's point of view.

And therein lies the killer app that can drive widespread adoption. Build an app that patients demand.

And it's not personal health records (remember Google Health?)  Instead it needs to solve an immediate problem for a large number of people. I suggest an app  that over 1 million new patients every year have a need for 3-6 months. That happens to be the number and recovery period for total hip and knee replacements (not partial, or repairs) in the United States.  

There are evidence based protocols and procedures for optimal outcomes from surgery to full recovery over a multitude of care settings.

But who is coordinating this effort over the entire lifespan?  Is it:

  • The insurance company (or Medicare)?
  • Primary care physician?
  • Rehab center?
  • Physical therapist?

All of those answers are incorrect.

In  healthcare the presiding belief is that care manager is on the provider side of the house. In reality it is the patient or in many cases the patient's advocate. The patient advocate role could be the patient, significant other or a family member. Things get very complicated when the advocate is caring for Mom who lives three states away.

This is reality.

300px-ArgonautDeviceWe need to build a post acute care platform with a FHIR component.  But it goes beyond health records.  This is the place that the patient advocate can coordinate, collect, manage and distribute information needed for the patient's full recovery (the use cases are numerous blog posts in themselves).  Everything from medication reconciliation, getting DICOM images to the therapist, through hiring Task Rabbit to take Mom to the grocery store or find a plumber to fix the leaking faucet.

By moving the focus to the patient, several authentication and state issues can be avoided. Firstly, patients have access to their records regardless of the state involved.  As for authentication, the patient has a key ring of OAuth tokens where their identity is confirmed by each medical provider or other entity.  (it's signing into a new service using Google in reverse, where the patient is Google).

Create an application like this and FHIR will take off - Because the patient advocate will demand it.

 


Big Data + Analytics = A Very Large Junkyard

Have a problem, Big Data will solve it.  The problem still is in data architecture and appropriate analytics.   And most importantly, understanding the business reason for this Big Data (solve a problem, discover new insights, etc.)

Today's tools are cheap and powerful.  For instance you can download the open source edition of Pentaho to your desktop.  It will connect to numerous data sources including Hadoop.   You now have a very large haystack to find a needle.

It's like have the world's largest junkyard and you want to buy a used 2001 Ford Focus with a broken water pump.  You can design a data architecture that links to all the junkyards in three states, NAPA Junkyardfor new pumps and car dealers.  You then develop the analytics to determine where to buy the water pump.  And you find one 2 states over that can pull and ship you just what you need.   

Problem solved, right?

What you missed was the fact that the water pump was very scarce.  Why is that?  Perhaps that model year had massive water pump failures.  By investigating further you may have seen that model year had above average repairs and perhaps buying it in the first place was not a good idea.

Wrong needle, right haystack.  And that takes planning with insight.  


Protecting against data breaches in your startup company: Apple + Box

Data security can be the furthest from your mind when doing your startup company.  You have a short runway to get a product out the door and get happy customers.  Security?  Spending scarce resources on it?

I am helping a company now with these very same questions.  The path of least resistance has been to standardize on Box business plan for all data and Apple computers and devices.  Why?   From a cost basis, they are very economical and they have the necessary security bells and whistles you need today.  And most importantly, the users like them and will use them (and you don't need a part time IT person to manage them).

The first thing I do is turn on 2 factor authentication (when you login on a new device, a code is sent to your phone for verification).  Both Box and Google for business support this.  I turn on full disk encryption for Apple computers (put in a password) and passcodes for iPads and iPhones.  And enable the ability to remote wipe any stolen or lost computer or device.  Pretty simple, but you  Wellwould be surprised at the number of people who don't do this.  And it's built in (no additional cost).

On the Box side, make sure you require a passcode to access it from your iPad or iPhone.  Since you have Box business, pin devices / computers to your users and you can restrict what applications your users use with Box.  You can restrict content that can be shared or not.

With Apple and Box, you get a lot of data security built in.   Think of this as a security well.  

You start at the top with the basics and as you grow you increase security measures as you progress down the well and need more protection.   Now that wasn't that hard was it?


Protecting yourself from hacked credit card readers: Google Wallet & Apple Pay

First TJX with 90 million accounts stolen, then Target with 40 million accounts stolen and now Home Depot with 56 million accounts stolen.  I found it interesting that Target was hacked through a flaw in Microsoft Active Directoy.  No news yet on the details of Home Depot.

What's a person to do?   Buy a phone with NFC payment option.  The newer Android phones have Google Wallet and it looks like Apple Pay is coming soon.  When you activate Google Wallet, you link it to a credit card.  I prefer American Express because they have great anti-fraud detection and allow you to dispute un-authorized charges from their website.

When you are shopping, look for the wireless payment option on the card reader.  Most grocery stores have them and big chains like Best Buy.  Walmart is too cheap and does not (use cash if you must shop there).   WirelessWhen you touch your phone to the card reader, Google prompts you for a pin.  And that's it.  What's interesting is that to the card reader, it looks like a single use Master Card regardless of your actual credit card.  And you need a data connection, because Google sends out the authorization code real time.  Pretty cool.  On your credit card statement it will say GOOGNFC*merchant name

If your phone gets misplaced, you can deactivate your wallet from the Google website.  Of course you have 2-factor authentication for your Google account, right?  And you have a lock code on your phone. And a good PIN for Google Wallet.

Bottom line, if that card reader was hacked, the bad guys only get a fictitious credit card number that can't be used.  Not bad.

 


Why Are You Special?

And by you, I mean your customers.   How do they view you?   Why did they buy and will they buy Customeragain?  This is the first question I try to understand whenever I start a new project (or talk to a company about a position). 

Once we figure that out, then you only need to do two things:

  1. Do more of what is special.
  2. Eliminate or automate anything that does not contribute to number 1.

The problem I see in many companies is they follow the latest "process" without understanding what is different about them versus everyone else.   On the other side of the coin I also see companies who generate plenty of good ides, without having the means to test and execute on them.

In my last consulting engagement it turned out that what management thought was "special" was completely different than what their customers thought.  In three months after going through the two steps above, revenue increased by 80%. 

Think about your specialness from your customers' eyes.


Designing for Privacy & Security : All your base are belong to us

Last week I had a lively discussion with an education expert talking about privacy and security.  This resulted after interpretations of FERPA resulted in universities selling student directories / email addresses to spammers third party marketing organizations. (just because they can, doesn't mean they should).

Then we moved on to the topic of security.   I always start with the assumption that all systems will be compromised, either externally or internally.   That is reality.  But it can be managed.  Starting with that premise, how do you design or improve your system?

First you need to compartmentalize your system to the smallest discrete pieces.  So if one compartment is compromised, none of the others will be.  Cloud systems tend to be monolithic silos.  Break into one part and everything else is exposed.   At my last company we built a separate virtual instance for each customer.  That way if one customer was compromised, it had zero effect on anyone else.

We also segregated the data (we were dealing with patient health records).  But we needed subsets of that data aggregated to do analytics.  Pulling the data is very bad, because that creates a single point of weakness.  Instead, each instance pushed the summary data to the aggregation database. 

Next you need audit.  Record everything.  And make sure that the system administration role is completely seperate from the auditing role.

Finally you need remediation.  What are the protocols to observe when any part of the system is compromised?  

  • Isolate it
  • Fix it
  • Notify those effected
  • Identify the root cause
  • Change to eliminate the root cause

This goes beyond system design into understanding how your customer / users need to interact with the system.  Do all new users really need to default to administrator role?

It is our job to take security and privacy seriously and engage our users to make sure they have what they need without making their lives more difficult (give me two-factor authentication to my cell phone over complicated passwords any day).

update:  I showed this blog post to a college student and they thought I had typos in my title.  To complete your education on video game nostalgia, read this.


Living in the HealthCare IT Bubble

Reality is a harsh mistress.  With the advances in Electronic Health Records, patient portals and records transport ala Direct X.509, my peers and I see a very bright future for healthcare in the U.S. and talk about all the great things we have accomplished.

Then a friend gets sick and enters the U.S. medical system and the bubble bursts.  The following happened over the last two weeks.   They have an issue and go to the ER of an Atlanta hospital.  Afterwards they are sent to their primary care physician and get a blood workup.  And sent for a CT scan at the imaging center.   The physician, hospital and imaging center are part of the same healthcare delivery system and all have the same EHR from a company in Tampa Florida.

First I contacted the medical records department at the hospital to get the CCD for the ER visit through their patient portal.  After being directed to four different people, they had no idea what a patient portal was.

The blood panel came back from the lab and since the physician had no patient portal, they sent a fax of the results.  The physician got the CT scan and was concerned (if you guessed the imaging center didn't have a patient portal, you would be correct).

My friend was sent to a surgeon on a referral.  During his examination he prescribed a simple medical procedure to correct what he saw.  He too was part of the network, but never got the CT scan or physicians report and we did not have copies.  Fortunately it was brought to his attention before he left, he ordered a rush on the reports and he scheduled surgery.

In the hospital the mishaps continued.  During prep for surgery the anesthesiologist went over the check list and stated the patient weighed 110 kilograms.  She was corrected and told 110 pounds.  The surgical nurse said not to worry, it happens all the time with the EHR but they always catch it in the operating room.

After the surgery and a few days on the med-surgical ward, the physician specifically prescribed a non-opiate pain medication.  Well, the pharmacy couldn't deliver it in 6 hours so she was given an opiate and had a severe reaction to it. 

6 hours later she was given the correct drug, to be repeated in 6 hours.  3 hours later the nurse came in to deliver the next dose.  She hadn't looked carefully at the chart.  When questioned, she said it was no big deal because the system would have caught it.

In discussions with the physicians and staff, it turns out they do have an patient portal.  It just doesn't work.

And this is one of the best hospital systems in Atlanta.  I'm sure they collect their MU1 and MU2 payments.  And the CEO makes over $1.5M a year.

added: Overall, the staff and the physicians are excellent.  Poor UX design, implementation and training resulted in these issues, and that's on us.  Depending on a system to catch your medication errors is like waiting to change the oil in your car when the check engine light comes on.  And that's a training issue all the way up to the CEO!

We have a lot of work to do.

 


Changing the Language of Healthcare from Cost to Outcomes and Productivity

The US healthcare system has been warped by reimbursements for care.  In Sharin's piece "The End of Hospital Cost Shifting", he talks about the impact on hospitals of the Medicare cutting reimbursements to hospitals based on work done by Austin Frakt

  • Cost shifting: Increasing the prices it charges commercially-insured individuals to compensate for reduced Medicare reimbursement.
  • Cost cutting.  Reduce cost for all patients to ensure average profitability across the entire Medicare/commercial payer mix.
  • Reduce profit margins.  Reduced Medicare reimbursement could simply eat away at hospital profits.

And he notes that cost cutting is the most likely result and that would impact patient outcomes:

Wu and Shen (2011) found that hospitals that faced large payment cuts from the 1997 Balanced Budget Act cut operating costs and staff and experienced increased mortality rates of heart attack patients relative to those seen at hospitals that faced smaller cuts.  They calculated that a 1 percent cut in payment results in a 0.4 percent increase in heart attack mortality rates.

And he concludes:

Such a trade-off calls to mind what Mark Pauly expressed in a 2011 paper in Health Affairs, “Perhaps a little less quality for a lot less money might be acceptable to consumers and taxpayers, as we work to keep medical spending from siphoning off funds required for other needs” (Pauly 2011). Whether it is acceptable or not, it may be what consumers and taxpayers get.

Let me break it down: Lower quality = worse patient outcomes = increased mortality = more people die.   And that's o.k. because it costs less.

And that's where the vocabulary is just wrong.  Nowhere does he focus on productivity improvement, resource utilization and the impact on outcomes.  They just don't think like that.  But every other industry does, except healthcare.  

I don't accept that more people dying in hospitals or post acute care is an acceptable tradeoff for lowering costs and I hope you don't either.


It's time to retire CPT® in health care

CPT (Current Procedural Terminology) is a medical billing coding system created by the American Medical Association (AMA) with the sole purpose of charging insurance companies for health care services and putting royalty money in the AMA's pocket.  Cpt-2014-professional-pIt's an artifact of the pay for service reimbursement system that has caused the US to spend the most on healthcare while delivering mediocre patient results.

If a CPT code does not exist for a service, chances are your physician won't do it.  Wonder why adverse drug reactions are under reported?  There is no CPT code for that. 

There is absolutely no relationship between good CPT coding and good patient care.  And there is no relationship between CTP code reimbursement rates and what those services actually costs a provider.  (Just ask the CEO of any hospital how much it costs them to perform a hip replacement.)

Sad but true.

The insurance companies are basically a cost plus business, so they focus on reducing the price paid per CPT.  The American Medical Association makes a from licensing the codes, so they have no incentive to change it.

Hopefully new "pay for performance" mandates in PPACA will shift the power to patient care quality / results from this very broken system.  And the AMA will have to find other ways to make money. 

CPT® is registered trademark of the American Medical Association.