Category Archives: Prevention

The Myth of Prevention and EHR’s?

Prevention (prĭ-vĕn ‘shən) n.

  1. Preventing or slowing the course of an illness or disease
  2. Intended or used to prevent or hinder; acting as an obstacle
  3. Carried out to deter expected aggression by hostile forces.

I was just referred this article which I found to be thoughtfully crafted. Abraham Verghese is a Professor and Senior Associate Chair for the Theory and Practice of Medicine at Stanford University. I found the article interesting, by somewhat anachronistic in terms of his perception of prevention and electronic medical records.

First, he raises an important point about the many overstatements as they relate to prevention. When we talk about how effective screening programs could be in identifying people for early interventions we have to realize what we are saying and what tools we are using for identification. Some tools can be too blunt, and not find the people we are looking for (false negatives), while other tools can be too sensitive and capture too many who actually may not have the disease (false positives). This is brought home in the example Dr. Verghese uses around the pitfalls of new diagnostic imaging equipment (and the situation is much worse with genetic testing at this point in time!). With these newer, more sensitive imaging studies you can pick up calcium deposits in a health individual can lead you down a pretty wild (and expensive) goose chase for someone who is completely asymptomatic. He also demonstrates that the “value” of some prevention recommendations as somewhat questionable  – meaning – that while taking cholesterol lowering drugs has clearly shown to be efficacy reducing cholesterol levels and cardiac risk, is it really worth $150K/additional life year extended?

Well, that depends on if it is your life I assume. My point being, that you need additional information to be able to make these difficult, complex decisions. You need to not only know the relative efficacy of the regimen, but also the cost of the regimen to truly get at the “value” of the intervention. In addition, patients have modifiers to which they will place on the intervention in terms of cost in time, pain, and other inconveniences that are unique to their own values. This is where shared medical decision making can have such an impact – lay out the good, the bad, and the ugly and allow the patient to make a decision based on all the available evidence according to their own value system.

I don’t think these types of decisions can be made with the type of information we have today within the current clinical infrastructure. First, the physician gets paid to order the test and not talk to you about whether or not pros and cons of whether you should get it. Furthermore, the doctor has very little to no data upon which to inform that conversations anyway. In the relatively rare areas in which we have evidence, we might not have other components required for decision making in terms of cost and experience of patients undergoing regimen. In the case of prevention items mentioned above, we might choose not to go on statins at $150K per year but instead invest $10,000 in a personal trainer who is going to get rid of the root problem anyway. Without the underlying information, this would never even surface as part of the decision making process. We absolutely must be gathering, comparing, and sharing result outcomes in order to increase our capacity as healers who use the right treatments for the right patients at the right time and in the right way.

Which leads me to my final point – you absolutely need EMR’s to function as an 21st century physician knowledge worker. We are purveyros, translators, and mediators of medical information for our patients. They can get most of it on their own now, but we can still add significant value through our interpretation, personal experience, and ability to process the myriad data points with our clinical acumen (the sum total of our diagnostic prowess which comes from experience, practice, expertise, and intuition). The EMR can be a very effective tool to help us gather, process, and present this information in a way that is meaningful and useful to our patients (actually most EHR’s don’t do this natively today, but with little effort a physician can lift the required information and present it in a format that is highly useful [alling all designers – get into health care!]). Furthermore, I truly dislike the characterization that the EHR makes the relationship cold and sterile.  I believe the current  generation of physicians, who have all grown up with the internet, see the EHR as an indispensible tool that helps them be more effective, efficient, and caring for their patients.

My sense is that I am more optimistic that we will get there with prevention, and that EHR’s will play a vital role to give us the clinical feedback to know whether our treatments (or prevention) efforts are having the impact that we hoped. Furthermore, I am hopeful, that efforts like the X PRIZE and others will help drive us to associate those outcomes with the total costs required to help us acheive the results so we can begin to understand the true value of the intervention. It is in this setting of data liquidity and information transparency, that they myth dissipates into a new reality of next generation medicine.


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Filed under EHR, Healthcare, Prevention, Quality, Transparency

SOAP: Apply, Rinse, and Repeat

SOAP (sōp) n.

  1. A cleansing agent, manufactured in bars, granules, flakes, or liquid form, made from a mixture of the sodium salts of various fatty acids of natural oils and fats.
  2. A process of medical evaluation and management which involves subjective, objective, assessment, and plan components.
  3. Slang. Money, especially that which is used for bribery.

I have my 10 year Medical School reunion this year. It is hard to imaging that 10 years have flown by since those halcyon days at the University of Utah. Ahhh, the memories: the incredible pervasiveness of the anatomy lab smell, the 12 hour study sessions in the library, the all night test preparation, the 12 hour study sessions, the incredible pathetic instruction (I eventually completely bailed on going to class), getting introduced to the pharmaceutical pimps, the 12 hour study sessions, passing boards, starting on the wards, proud of my white coat, completely embarrassed that I was but a shell of limited knowledge within the white coat, completely arrogant attendings, even more arrogant residents, cool patients, amazing medical science, powerless medical science, trying to figure out what specialty to go into (what respectable student would “settle” for primary care), spending 5 weeks in Palau, passing Step II, match day, and ultimately graduation day. Whew – memory lane.

In reminiscing, many of the most memorable experiences were the many bizarre and absurd situations you find yourself in. One of those, involved SOAP and learning how to do the physical exam from a legendary figure named Bruce (the latter half of the story can only be shared in person).

For the medically inclined, SOAP stands for a simple paradigm of the medical thought process encapsulated in the daily note you make on patients when you “round” in the hospital. SOAP stands for Subjective, Objective, Assessment, and Plan. It is used daily, by millions of providers, as a simple way to think about the care process. First, you take a Subjective history; typically writing down the exact words that the patient uses to describe their “Chief Complaint”. It is subjective because it is what the patient perceives, experiences, or the manner in which they relate or describe their situation. Next, you perform an Objective physical exam. This is the concrete stuff that you can personally observe, elicit, palpate, or document in some hard, reproducible way. Based on the above, you develop an Assessment of the situation. The Assessment is where the diagnosticians can pontificate and conjecture on the theory behind the illness (and where the surgeons write, “Doing well” regardless of the clinical situation). Based on this, a clinical care Plan is created for the patient from which the team continues to manage patient’s care (and the surgeons write “DC with +BS” [discharge with bowel sounds]). SOAP – short, simple, and systemic way providers think about the daily management of their patients.

Turns out that SOAP has broader implications. As you consider many of the new services being promoted or benefit designs being developed, SOAP provides an excellent framework and sturdy foundation from which to create a health, wellness, or prevention plan. In fact, if you review the materials being created by groups like US Preventive Medicine, they are following the SOAP format to a T as part of their “Prevention Plan“.

USPM is helping people to complete a Subjective evaluation in the form of a Health Risk Assessment. Patients fill out a comprehensive evaluation of their health status, including socio-economic, behavioral, and family/social histories. This is patient generated content and therefore it has an appropriate, but not preeminent place in the medical context. Next, they complete a battery of health and wellness laboratory tests (Assessment) to establish a health status baseline. These tests, and the testing process, form a critical part of the overall evaluation. The patients then undergo a full physical exam to obtain the Objective data that USPM providers will need to create a personalized Prevention Plan.

By using the SOAP approach – USPM is creating a simple and systematic way to engage their patients in a iterative process of evaluation / re-evaluation that fits well into a managed prevention plan – a great concept that I have noted before. By having a solid prevention Plan in place, and adjusting as new SOA information becomes avaiable, an individual can modify their behaviors to ensure a “clean” bill of health.

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Filed under Consumerism, Health Plan 2.0, Prevention, Value