January 18, 2014

EHR Flawed and Open to Fraud

I am not concerned which name you use for medical records, but the opportunity for fraud and misuse of our medical records is becoming part of the medical problem in rising costs. I have not seen many great articles about this problem, but the NY Times is one of the better articles. The other problem I am seeing very little about is the electronic theft of many medical records from doctors' offices and hospitals.

The federal government is spending more than $22 billion to encourage hospitals and doctors to adopt electronic health records (EHRs). You would think that with this money would come some safeguards to prevent inflating costs and over billing. This is the second report issued in two months by the Office of the Inspector General (OIG) for the Health and Human Services Department, but to date, no one shows any concern.

According to the report, the government has directed very little attention to prevent fraud and other abuses of EHRs. Medicare has not changed how it detects fraud and has provided its contractors with limited guidance. The OIG report was critical of the copy and paste function available in many of the largest electronic health record systems. The result, some critics say, is that hospitals and doctors are overcharging Medicare for the care they are providing. The report did not estimate the amount of fraud that may be occurring, but earlier government estimates have said it could run in the hundreds of millions of dollars. Although the amount is a fraction of the trillions of dollars spent annually on health care, the lack of safeguards at a time when the new technology is becoming pervasive could allow the fraud to balloon.

In the prior report, the OIG found that three-quarters of the hospitals it surveyed had no formal policy for the use of copy and paste for electronic records. Of course, Medicare officials said preventing fraud is a top priority. This has been a statement that has been overused year after year and fraud continues. We always hear about it when a big fraud case is stopped, but we seldom hear about other fraud being stopped much less prevented.

I am not reassured by their statement that they are developing better instructions for their contractors. Then they dispute the OIG recommendation about how contractors should detect fraud. Apparently, if as hospital says it has something in place, the hospital should not be inspected. I say this is when inspection becomes necessary as they are probably hiding something. From my short stint as an auditor, I know this was generally true.

I find the statement by Linda E. Fishman, a senior executive for public policy at the American Hospital Association even more suspicious. When she says, “Hospitals already have strong safeguards,” she is just attempting to close the door when the horses have already gone.

The one statement I do believe is this by Dr. Ashish K. Jha, professor of health policy at the Harvard School of Public Health, who states, “As much as electronic records have the potential to provide better care, many are disappointed in the current technology. The boosters of electronic health records spent a lot of years overhyping and overselling it.”

Please read the NY Times article.

January 17, 2014

Medical Research May Now Be Beyond Redemption

The source of this blog is a Scottish General Practitioner, Dr. Malcolm Kendrick. What he says is very true and I would agree with him. He states that medicine today is heading in the wrong direction with over-diagnosis and over-treatment. In other words, polypharmacy is becoming a massive problem.

This is driven mainly by the pharmaceutical industry – an industry that wants to see the entire population of the world taking medication every day and forever. He clearly says that the industry has grabbed hold of medical research and twisted it to their own ends.

I would caution that in reading his blog, many spellings are not American, but British spellings. He quotes an article from the British Medical Journal (BMJ) and adds comments to avoid copyright quarrels. I will encourage you to read his blog, as I will summarize for my understanding. Dr. Kendrick says this about the BMJ - they are the only major journal that seems keen to criticize the industry.

Evidence based medicine (EBM) was opposite the drug industry in the 1990's. Doctors could ward off an army of pharmaceutical representatives because their promotional material was devoid of evidence. About the turn of the century, the drug industry realized that EBM was an opportunity rather than a threat, and when published in a prestigious journal was worth more than thousands of sales reps.

Today, without evidence, there is no seat at the guideline table. This is now the elephant in the room because the drug industry controls and funds most research. The drug industry and EBM have set about legitimizing illegitimate diagnoses and then widening drug indications. Today doctors can prescribe a pill for every ill.

The 66 percent increase in prescription in one decade in England does not reflect a true increase in burden of illness or an ageing population, just polypharmacy supposedly based on evidence. The drug industry’s corporate mission is to make us all sick, regardless of how well we feel.

Clinical research in now corrupt and the promotion is passed off as postgraduate education. I suspect that medical schools will be the next area for expansion to recruit doctors in the formative years. Then when they graduate, they will promote polypharmacy.

Dr. Kendrick says we are at a crisis point. Medical research today is almost beyond redemption. I know he is talking about England, but this applies to the United States as well and the drug industry has bought their way into most research and is strongly influencing doctors in their prescribing habits. When we have the American Association of Clinical Endocrinologists training the drug reps how to promote drugs more effectively, most officers of the ADA and AACE having large conflicts of interest as well as many of our doctors getting paid for speaking, and promoting different medications by the drug industry, what are we to think.

January 16, 2014

Frozen Shoulder – Diabetes Related?

This is a topic I have been requested to write about by a reader, but since I have been fortunate not to have this problem, I will be pulling information from several sources. Basically, at present, there is little known as to the cause and often this cannot be determined. Yes, they know what happens – inflammation and the arm is stiff and difficult to move freely.

Most of the time there is no cause for frozen shoulder, but the risk factors include:
  • Cervical disk disease of the neck
  • Diabetes
  • Shoulder injury
  • Shoulder surgery
  • Open heart surgery
  • Thyroid problems

These are the most known and there may be other reasons for frozen shoulder or adhesive capsulitis as it is medically named. I think that the Mayo Clinic oversimplifies when they declare - “Treatment for frozen shoulder involves stretching exercises and, sometimes, the injection of corticosteroids and numbing medications into the joint capsule. In a small percentage of cases, surgery may be needed to loosen the joint capsule so that it can move more freely.”

The U.S. National Library of Medicine gives the main symptoms as:
  • Decreased motion of the shoulder
  • Pain
  • Stiffness

Frozen shoulder without any known cause starts with pain. The pain prevents you from moving your arm. Lack of movement leads to stiffness and then even less motion. Over time, you become unable to do movements such as reaching over your head or behind you.

Frozen shoulder occurs:
  • After surgery or injury.
  • Most often in people 40 to 70 years old.
  • More often in women, especially in postmenopausal women, than in men.
  • Most often in people with chronic diseases.

A doctor will normally ask you for symptoms and examine your shoulder and let you demonstrate the range of motion. Often the doctor will make a diagnosis when you are unable to rotate your shoulder. Some doctors will x-ray the shoulder and others will use an MRI to look for inflammation. X-rays are used to eliminate other problems, such as arthritis.

Treatment will also vary by the doctor. Many doctors will only treat the pain with nonsteroidal anti-inflammatory medications (NSAIDs). Others will treat with steroid injections and refer you to physical therapy, which often improves your motion.  I can only trust that it takes a few weeks to see improvement and up to nine months for a complete recovery. Physical therapy can be intense and needs to be done every day. Some have said that if left untreated, the frozen shoulder often becomes healed within two years with little loss of motion.

Risk factors for frozen shoulder, such as diabetes or thyroid problems, should also be treated. Surgery is recommended if nonsurgical treatment does not work. Shoulder arthroscopy is done under anesthesia and scar tissue is released to bring the shoulder through a full range of motion. This surgery may also be used to cut tight ligaments and remove the scar tissue. Pain blocks are given so participation in physical therapy is not hampered.

People with diabetes that maintain excellent management are less likely to get frozen shoulder, but some still do even with excellent management. Always contact your doctor if you develop shoulder pain that limits your range of motion. Early treatment and physical therapy helps prevent stiffness.

Tom Ross at Not Medicated Yet published a blog review of his episodes with frozen shoulder on January 13, 2014. You may also wish to read a 2004 blog by David Mendosa.

January 15, 2014

Pharmacists Now Doing More for People With Diabetes

I must admit my feeling about the help that pharmacists are providing to people with diabetes is very positive. Pharmacists are stepping up their public relations (PR), putting their activities into action, and doing a lot more for all people with diabetes than certified diabetes educators (CDEs) have done in a long time.

This action started five years ago in a hunt for the cause of hypoglycemia in the 11 hospitals in the BJC HealthCare system according to Paul Milligan, PharmD, medication safety officer at BJC HealthCare in St. Louis, Missouri. First they realized that adverse drug events were responsible of 20 percent of the preventable harm that occurred in their system. Next they lead a multidisciplinary mission to reduce them.

What they discovered was that 77 percent of the adverse events were caused by severe hypoglycemia. Dr. Milligan described this as a hidden epidemic that was not on anybody's radar. This was discovered by working with each hospitals informatics department to track the origin of drug events. That revelation presented particular challenges. Hypoglycemia has assorted and complex root causes - from prescribing, to drug administration, to patient compliance, to food issues, to equipment variances. Dr. Milligan explained that the population available to study was very large — about a third of the patients in the system had diabetes.

This was not what they had expected, but because clinicians mainly focus on the primary reason the patient is admitted to the hospital, and diabetes is often secondary.  Making the problem even more complex was when pharmacists teamed up with physicians, nurses, dietitians, and diabetes educators to study the problem at 11 hospitals in the BJC system. This team discovered that each hospital had a different primary root cause for the hypoglycemia. At one hospital, the 3 people delivering the food, testing the blood, and delivering the insulin came in at different times, so could not perform their actions simultaneously, which is preferable. At another hospital, admitted patients were getting fewer calories than they did at home, but were receiving the same medication dose, which caused blood sugar to drop.
Once the root causes were determined, the team developed procedures customized to each hospital. That was one key to BJC's success, because they didn't try to implement one standard list across all the hospitals. We dealt with the biggest problem at each hospital, and sometimes only on the problem floors. You get a big impact and bigger buy-in if staff can see direct results.

Elizabeth Pratt, DNP, RN, from Barnes-Jewish Hospital, which is part of BJC HealthCare, said some of the problem was a lack of awareness among clinicians about hypoglycemic trends in patients and a lack of automated triggers that would alert clinicians to monitor glucose levels.”

"With heightened awareness and an alert system, we're able to recognize those people earlier, have a multidisciplinary discussion with the nurses, pharmacists, and physicians," and ask whether the regimen should be adjusted, she said.

Now that the initial problems are under control, Dr. Pratt has taken over maintenance of the program, system-wide. In 2014, the program will be expanded to include the prevention and treatment of hyperglycemia, she reported.

Now, instead of an average 138 such events per month, the system averages in the 30s, said Paul Milligan, PharmD, medication safety officer at BJC HealthCare in St. Louis, Missouri. The team has been credited with preventing more than 2100 hypoglycemic events, which saved 8127 inpatient days and more than $7 million in hospital costs.

January 14, 2014

High Fructose Corn Syrup Again In the News

Now that the Food and Drug administration has declared trans fat unsafe, consumer groups already have their next target in the cross hair for elimination, or tighter regulation. This target is high fructose corn syrup (HFCS) and there is a lot of anticipation that there will be success. Those of us with diabetes won't feel hurt if they are successful in removing it from foods.

#1. It is a highly processed ingredient shrouded in secrecy.

#2. It causes damage to the liver and spikes the blood glucose for people with diabetes.

#3. The corn processors spend millions on lobbyists, TV ads, and highly paid advocates in an attempt to convince consumers that their product is safe.

#4. As health concerns escalate, food companies, supermarkets, and restaurants will voluntarily remove this ingredient.

#5. Some communities are banning or restricting HFCS to halt the ever-increasing medical costs associated with HFCS.

#6. When lawsuits start multiplying and claiming HFCS causes serious health damage, the product will become less prevalent.

As clinical evidence against HFCS mounts, independent researchers are going on record to alert consumers about its health risks. This includes Dr. Robert H. Lustig, Dr. Mark Hyman, Chairman of the Institute for Functional Medicine, and Dr. Michael Goran, Director of the Childhood Obesity Research Center.

Citizens for Health has filed a petition asking the FDA to take action against food and beverage manufacturers that use HFCS concentrations above approved limits, and to require accurate HFCS labeling information. This is the one area I feel will be the greatest help and reducing the amount of HFCS in our foods.

January 13, 2014

Depression May Be Linked to Low Zinc Levels

Because soils in the United States are generally low in levels of zinc, this may well be factual and part of the depression problem. Granted this is the determination of a meta-analysis and not a large controlled study. In addition, the authors list some weaknesses of the studies they used. Association studies cannot determine the direction of causation, a causal association between zinc status and depression is biologically plausible.

Zinc does have antioxidant properties, it helps to maintain endocrine homeostasis and immune function, and zinc plays multiple roles in regulating the hippocampal and cortical glutamatergic circuits that sub serve regulation and cognitive function. Thus, changes in zinc homeostasis might compromise neuroplasticity and contribute to long-term neuropsychological and psychiatric decline. Homeostasis is the tendency of a system, especially the physiological system of higher animals, to maintain internal stability, owing to the coordinated response of its parts to any situation or stimulus that would tend to disturb its normal condition or function.

People who are depressed were found to have lower concentrations of zinc in their peripheral blood compared with nondepressed individuals, a meta-analysis suggests.  The pathophysiological relationships between zinc status and depression, and the potential benefits of zinc supplementation in depressed patients, does warrant further investigation. This is the conclusion of author Walter Swardfager, PhD, from the Sunnybrook Research Institute, University of Toronto, Canada, and colleagues. Their findings were published in the December 15 issue of Biological Psychiatry.

The analysis included 17 studies that measured peripheral blood–zinc concentrations in 1643 depressed patients and 804 control participants. Ten of these studies reported on psychiatric inpatients, and seven reported on community samples. Of the participants, 34.4% were male; the mean age was 37.7 years.

I found no mention in the study about whether the following vitamins, B12 and B6, which can also influence depression were even considered. From my research, I know that vitamin B12 and vitamin B6 can influence depression. From the Oregon State University the following is quoted from depression - “Because a key enzyme in the synthesis of the neurotransmitters serotonin and norepinephrine is PLP-dependent, it has been suggested that vitamin B6 deficiency may lead to depression. However, clinical trials have not provided convincing evidence that vitamin B6 supplementation is an effective treatment for depression, though vitamin B6 may have therapeutic efficacy in premenopausal women.”

Also from the Oregon State University, this is quoted from the vitamin B12 - “Observational studies have found as many as 30% of patients hospitalized for depression are deficient in vitamin B12. A cross-sectional study of 700 community-living, physically disabled women over the age of 65 found that vitamin B12 deficient women were twice as likely to be severely depressed as non-deficient women. A population-based study in 3,884 elderly men and women with depressive disorders found that those with vitamin B12 deficiency were almost 70% more likely to experience depression than those with normal vitamin B12 status.”

Rather than purchasing and taking zinc supplements, I would suggest that you talk this over with your doctor and have the doctor test for serum zinc deficiency. Be careful, as many doctors will declare that this is “all in your head.” A member of our support group had a relative with depression and this was the answer she received. The doctor also said the same for B12 and B6 and refused to test for them.

We are thankful that our local doctor, Dr. Tom, as we have nicknamed him, that knows our group fairly well now, did the tests for Sue's relative and discovered she was severely deficient for zinc, iron, and vitamin B12. He gave a series of shots for the B12 and started her on iron supplements immediately. He said because iron could prevent the uptake of zinc, he wanted her iron levels in the normal range before she took any zinc supplements. Sue's relative recovered from her depression before she started on the zinc supplement. There were other vitamins that the doctor discovered she was in the low range for and they started tackling them with food to start, and when one still tested low, he prescribed a supplement for it.

We have invited him to speak to a joint meeting of his support group and our group in January. He has accepted this.

January 12, 2014

AADE Membership Numbers and Industry Sponsors

Apparently, I have ignored some of the activities of the American Association of Diabetes Educators (AADE) for too long. The membership has decreased from a reported 13,000 members per the AADE 2012 Fact Sheet to the latest number of 12,000, as shown in the AADE Career Opportunities. Why is this happening? There is no indication on the website and at least they are no longer claiming that their membership is growing as I questioned in my blog here.

I suspect that many have left the organization or discontinued their membership, but I have no proof, as they are very secretive about what compromises their membership. Because I have been critical of their organization, I cannot get anyone to answer an email for further information.

Further exploration of the AADE website confirms that they are continuing to ignore the National Standards for Diabetes Self-Management Education (DSME) and Diabetes Self-Management Support (DSMS) adopted by the ADA and written by members of the AADE and ADA. Another article calls these the Ten Gold Standards for Diabetes Self-Management Education.

These ten National Standards for Diabetes Self-Management Education is designed to define the quality of education and support for diabetics and pre-diabetics. A diverse group of health care providers reviews and revises the standards every five years. There are ten standards that diabetes educators and programs should follow in order to provide optimal care. The fact that the AADE has not adopted them or shown them in their Position Statements for 2013 or their 2013 Practice Advisories says they are not adopting them. Fact is they show no Position Statements for 2013. The AADE is still adhering to their standards for Diabetes Self-Management Education (DSME) and Training (DSMT).

In their Scope and Standards section they do have reference to the fact that the AADE collaborated with the American Diabetes Association to develop the 2012 National Standards for Diabetes Self-Management Education and Support. This is just the PDF file that is a copy of the ADA publication. There is no statement that they are adopted or if they are to be part of the AADE guidelines. I have blogged about the National Standards starting here.

The surprising find on the AADE website is their conflict of interest area in which they list the Industry Allies Council of the diabetes supplies manufacturers and pharmaceuticals manufacturers. The list is more inclusive that I had imagined and explains why certain medications are being heavily promoted by CDEs. This list can be read here.

In the past, I have wondered why the AADE would not establish a classification for lay people to help with diabetes education, especially for people with type 2 diabetes, but now, I will not encourage this with the conflict of interest being known. Instead, I will move my encouragement to organizations already making this happen and encourage medical schools to develop these activities and other higher educational institutions that have developed lay programs in the past.