Doctor Ordered Vacation

Had not wanted this, but to heal my injury more rapidly, I will be following doctors orders until I feel I can use my right hand again.   Tendonitis is the problem.  Hope it heals fast.

What You Don't Know Can Hurt – Even Kill You

“Is it possible for a health care system to redesign its services to better educate patients to deal with their immediate health issues and also become more savvy consumers of medicine in the long run?” This is an important question and even larger dilemma for the medical profession to solve. I would also state that the patients need to pay attention as this poses a question for patients - “How do patients make good choices?”

Two different articles from different perspectives are very interrelated and important for both sides in the near future. Even being aware of one side before I wrote this blog on the August 23, the blog posted by Nancy Finn on September 3 really brought the topics together for me. Both the medical profession and the patients have a challenge before them and solutions are not easy to come by. This also brings another question into play - “Can both sides work together to solve this?”

I will say that for many, this will be possible on both sides, but I wonder how we will bring those on both sides that will oppose this very rigorously into the desired state of learning. Many physicians are of the opinion that patients should listen only to them, the doctors, and follow their directions explicitly. On the patient side, there are many that will have no desire to learn and will insist on following the doctor without learning anything about the reasons or the medicine behind the condition.

The importance of health literacy is more important today than in the past for several reasons. People that are literate become more adept at understanding health information, tend to make more informed healthcare choices, become better able to manage their chronic conditions, and in general have significantly better outcomes than patients that remain health illiterate. Patients that remain healthcare illiterate have higher rates of medication errors, more emergency room visits, hospitalizations, and increased likelihood of dying.

A number of health policy organizations recognize that health literacy is important to individuals, and benefits society because helping patients help themselves is an important pathway to keeping down health care costs. Successful self-management reduces disease complications and can cut down on unnecessary emergency room visits and eliminate other wasteful spending.

Organizations that promote proper health literacy tend to do certain things very well. The ten (only nine are listed) attributes in the report include items such as:

1. Making improving health literacy a priority at every level of the organization;

2. Measuring health literacy and using those measurements to guide their practices;

3. Taking into account the particular needs of the populations they serve;

4. Avoiding stigmatizing people who lack health literacy;

5. Providing easy access to health information and assistance navigating services;

6. Distributing easy-to-understand information across print, audiovisual, and social media channels;

7. Taking health literacy into account when discussing medicines or in other high-risk situations by using proven educational techniques, such as the teach-back method;

8. Training the healthcare workforce in health communication techniques; and

9. Letting patients know what their insurance policies cover and what they are themselves responsible for paying.

When you consider what is on the plate for patients, the medical decisions have changed from leaving the choice of treatment entirely in the hands of your doctor to the patient now needing to be informed and choose between treatment choices. These decisions are often life altering, and it is now up you or your families to choose which way to treat your medical issues. This change has occurred because for many conditions:

(1) There are no clear-cut parameters with proven success;

(2) The medical experts differ regarding the best way; and

(3) Although there is an abundance of information about medical issues, that information is often difficult to comprehend.

Nancy Finn accurately explains many of the decisions we as patients may need to make and the task does look daunting to say the least. What may seem simplistic on the surface, can be very complicated when it is your life on the line. Healthcare literacy is important and if you have great doctors that are willing to take the time to educate you, the decisions will be difficult, but you will have a solid base on which to make the decision.

This is why becoming an e-patient may be a goal you need to set for yourself. Even then with all the diseases and types of illnesses, this is a formidable task. This is just one more reason that e-patients form groups that can mentor others.

Will New Tool Really Help Dietitians?

When I read this, I could not believe that this was being said by a registered dietitian. I mean that she is right in what she says, but to say it publicly has to be daring. It is so important that I am going to quote it, "Only 80 percent of the dietitians we surveyed did any pre-assessment of the client's nutrition literacy, which makes it difficult for educators to target their counseling so clients can understand and act on the information they are given." Karen Chapman-Novakofski is a registered dietitian (RD) and University of Illinois professor of nutrition extension.

From a profession that lives by its mandates, mantras, and dogma, this RD speaks very plainly about why dietitians and some nutritionists are often ignored by their clients. The attitude of RDs is so ingrained in their mantras that they do not pre-assess what their patient (client) has knowledge of and what they need to be taught to make the information useful.

I know that I am not surprised at her findings in the survey. Here we get into using terms that are not explained as well as they should be. Before today, I would have thought a nutrition educator was a teaching position at a college or university. On doing my research, this is true, but also encompasses nutrition educators in hospitals and medical centers as well. Some are also involved in business nutrition education, like agriculture businesses Archer Daniel Midlands, Monsanto, and the food industry.

If the 80 percent is from academia, and the medical arena, then this is why we get the mandates, mantras, and dogma. However, I do think that the term nutrition educators is just the latest phase we are going to have to get used to coming out of the Academy of Nutrition and Dietetics. A doctoral student, Heather Gibbs, has developed an algorithm that dietitians can use to determine precisely what knowledge and skills are required for a particular client.

I know algorithms can be very powerful tools, but I wonder how this will help a profession that works with mandates, mantras, and dogma. They seldom change and will avoid the algorithm as they are not as interested in education as they would lead you to believe. It could be that this may be about to change, but I would not get too enthused yet.

Some patients or clients as they are termed in this article need to know how to manage their consumption of carbohydrates, protein, and fat. Many more need to learn how to manage portion sizes and others need to learn how to read labels. Then many clients need to be able to categorize foods into nutrition groups properly. So with this algorithm dietitians will have the questions to assist them in assessing what the knowledge is that the client possesses and then teach the client what they need to know be become more nutritionally knowledgeable and manage their nutritional needs plus work to balance their daily nutrition.

Karen Chapman-Novakofski stresses that until health professional start asking questions to see what knowledge the patient has about nutrition, it will be impossible to effectively teach nutrition and create a behavior change. She also stated that until dietitians narrow their focus and understand what skills and literacy the client patient possesses, they cannot deliver information in a way that will be meaningful or usable by the client.

Dietitians must get away from the education level of the patient to understand that the patient and the level of nutrition they possess. Then the dietitians can adapt the education to fill in the gaps and make the information usable for the client. Chapman-Novakofski also said if you're the one being counseled, don't be afraid to ask “how” questions to force the dietitian to keep the discussion on your level.

The area Chapman-Novakofski did not cover was how to get the dietitian away from mandates, mantras, and dogma. Until these three areas are made useless to the dietitians, little nutritional education will be passed in a usable form for the clients.

Patients Not Seeing Progress in Meaningful-Use

The Centers for Medicare and Medicaid Services (CMS) on August 23, 2012  released the final version of its second-generation criteria for "meaningful use" of electronic health records (EHRs). This will supposedly make it easier for physicians to earn bonuses and avoid penalties; however, little in the final version will benefit patients and their ability to view online their medical records. Again, the resistance of the American Medical Association has reared it ugly head to continue to make it difficult for patients to have transparency of their EHRs.

Two areas where physicians were able to delay aggressive implementation are the electronic transmission of prescriptions and delay of ability of patients to have access to their EHRs. Neither of these should have been that difficult to accomplish, but the AMA in their infinite wisdom have lobbied for slowing the progression of e-prescribing and wanted to junk the provision for patient online access.

On the topic of electronic prescribing, Stage 1 required physicians to transmit more than 40 percent of their scripts to the pharmacy. CMS in the proposed rules wanted to increase the threshold to 65 percent. The AMA and other medical groups held out for 50 percent and the CMS settled on 50 percent in the final regulations.

I am not surprised that the AMA and organized medicine is so opposed to letting patients view their health data online – they have something to hide. They wanted this entire part of Stage 2 thrown out. CMS had proposed a rule allowing more that 10 percent of patients to have access to their EHRs starting with Stage 2. Organized medicine says that CMS should not hold physicians accountable for patient behavior beyond their control. Thank you CMS for keeping this provision as part of Stage 2, but you should not have lowered it to 5 percent.

CMS did regrettably give four exceptions to meaningful use penalties to Stage 2 in 2015 for not achieving meaningful use and they are:

1. Infrastructure: Clinicians must prove that they practice in an area with inadequate Internet access or "insurmountable barriers" to obtaining it.

2. New practitioners: Clinicians who begin practicing in 2015 would be exempt from the meaningful-use penalty in 2015 and 2016, but they would have to demonstrate meaningful use in 2016 to avoid the penalty in 2017.

3. Unforeseen circumstances: Physicians may be able to avoid a penalty if natural disaster or some other unforeseeable event prevented them from meeting EHR meaningful-use criteria. CMS will consider this exception on a case-by-case basis, and sparingly so.

4. Scope of practice: Medicare will refrain from penalizing physicians who cannot achieve meaningful use by virtue of how they practice. They may not routinely see patients face to face, for example, or they may practice in multiple locations where they have no control over the availability of EHR technology.

However, CMS is not afraid to tread in areas they maybe should not have. CMS did deny a proposed exception for physicians nearing retirement. AMA and its cohorts wanted to exempt physicians if they are currently eligible or would be eligible by 2014 for Social Security benefits. CMS simply stated that a practitioner's age does not constitute a significant hardship.