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Paying Attention to Detail Critical in Medical Coding
Documentation demands attention to detail. For a patient with abdominal pain, be sure to ask: How long has the patient experienced pain? Is it generalized or in a particular quadrant? Sharp or dull? And does it radiate? And jot down the answers.
“Try to use adjectives that would give specifics regarding the complaint,” says Mary Mulholland, MHA, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania’s department of medicine. She also suggests hospitalists find out which medications a patient is taking or has taken and indicate whether symptoms have improved or deteriorated. Here’s how Mulholland would document such a case:
Initial hospital admission, level of service:
Code 99223
83-year-old male admitted from the emergency room, complaining of intermittent crampy lower abdominal pain (severe at times), blood in stool and increased weakness for three weeks, worse when getting up or standing. Patient has decreased appetite and progressive shortness of breath. His review of systems is otherwise negative.
Past medical history: Coronary artery disease and hypertension
Family history: Mother with Type 2 diabetes
Social history: Quit smoking 20 years ago
Alert: Blood pressure (90/68), pulse (88), and respiratory (24)
Eyes: Non-icteric
ENT: Dry oral mucosa
Lymphatic: Palpable nodes—right auxilla and right inguinal areas
Lungs: Clear
Cardio: Slight tachycardia, no murmurs, rubs or gallops
Abdomen: Slightly distended, tender on palpation
Skin: Slightly diaphoretic, no rashes or bruising
Neurologic: Cranial nerves intact, alert and conversant
Psychiatric: Anxious
Lab results: Blood in stool, hemoglobin (6.7), serum blood glucose (120), serum sodium (132), serum potassium (4.3), chest X-ray clear (my interpretation). Old records requested.
Assessment: Gastrointestional bleeding, tachycardia, and mild dehydration
Treatment plan: Check hemoglobin and hematocrit every six hours. Also check prothrombin time and partial prothrombin time. Repeat electrolytes in the morning. Order an X-ray of the lower gastrointestinal tract. Type and screen for 2 units of packed red blood cells, and transfuse pending repeat hemoglobin and hematocrit values. Infuse intravenous fluids at 80 cc per minute. Check electrocardiogram. Consult GI regarding endoscopy.
—Susan Kreimer
Documentation demands attention to detail. For a patient with abdominal pain, be sure to ask: How long has the patient experienced pain? Is it generalized or in a particular quadrant? Sharp or dull? And does it radiate? And jot down the answers.
“Try to use adjectives that would give specifics regarding the complaint,” says Mary Mulholland, MHA, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania’s department of medicine. She also suggests hospitalists find out which medications a patient is taking or has taken and indicate whether symptoms have improved or deteriorated. Here’s how Mulholland would document such a case:
Initial hospital admission, level of service:
Code 99223
83-year-old male admitted from the emergency room, complaining of intermittent crampy lower abdominal pain (severe at times), blood in stool and increased weakness for three weeks, worse when getting up or standing. Patient has decreased appetite and progressive shortness of breath. His review of systems is otherwise negative.
Past medical history: Coronary artery disease and hypertension
Family history: Mother with Type 2 diabetes
Social history: Quit smoking 20 years ago
Alert: Blood pressure (90/68), pulse (88), and respiratory (24)
Eyes: Non-icteric
ENT: Dry oral mucosa
Lymphatic: Palpable nodes—right auxilla and right inguinal areas
Lungs: Clear
Cardio: Slight tachycardia, no murmurs, rubs or gallops
Abdomen: Slightly distended, tender on palpation
Skin: Slightly diaphoretic, no rashes or bruising
Neurologic: Cranial nerves intact, alert and conversant
Psychiatric: Anxious
Lab results: Blood in stool, hemoglobin (6.7), serum blood glucose (120), serum sodium (132), serum potassium (4.3), chest X-ray clear (my interpretation). Old records requested.
Assessment: Gastrointestional bleeding, tachycardia, and mild dehydration
Treatment plan: Check hemoglobin and hematocrit every six hours. Also check prothrombin time and partial prothrombin time. Repeat electrolytes in the morning. Order an X-ray of the lower gastrointestinal tract. Type and screen for 2 units of packed red blood cells, and transfuse pending repeat hemoglobin and hematocrit values. Infuse intravenous fluids at 80 cc per minute. Check electrocardiogram. Consult GI regarding endoscopy.
—Susan Kreimer
Documentation demands attention to detail. For a patient with abdominal pain, be sure to ask: How long has the patient experienced pain? Is it generalized or in a particular quadrant? Sharp or dull? And does it radiate? And jot down the answers.
“Try to use adjectives that would give specifics regarding the complaint,” says Mary Mulholland, MHA, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania’s department of medicine. She also suggests hospitalists find out which medications a patient is taking or has taken and indicate whether symptoms have improved or deteriorated. Here’s how Mulholland would document such a case:
Initial hospital admission, level of service:
Code 99223
83-year-old male admitted from the emergency room, complaining of intermittent crampy lower abdominal pain (severe at times), blood in stool and increased weakness for three weeks, worse when getting up or standing. Patient has decreased appetite and progressive shortness of breath. His review of systems is otherwise negative.
Past medical history: Coronary artery disease and hypertension
Family history: Mother with Type 2 diabetes
Social history: Quit smoking 20 years ago
Alert: Blood pressure (90/68), pulse (88), and respiratory (24)
Eyes: Non-icteric
ENT: Dry oral mucosa
Lymphatic: Palpable nodes—right auxilla and right inguinal areas
Lungs: Clear
Cardio: Slight tachycardia, no murmurs, rubs or gallops
Abdomen: Slightly distended, tender on palpation
Skin: Slightly diaphoretic, no rashes or bruising
Neurologic: Cranial nerves intact, alert and conversant
Psychiatric: Anxious
Lab results: Blood in stool, hemoglobin (6.7), serum blood glucose (120), serum sodium (132), serum potassium (4.3), chest X-ray clear (my interpretation). Old records requested.
Assessment: Gastrointestional bleeding, tachycardia, and mild dehydration
Treatment plan: Check hemoglobin and hematocrit every six hours. Also check prothrombin time and partial prothrombin time. Repeat electrolytes in the morning. Order an X-ray of the lower gastrointestinal tract. Type and screen for 2 units of packed red blood cells, and transfuse pending repeat hemoglobin and hematocrit values. Infuse intravenous fluids at 80 cc per minute. Check electrocardiogram. Consult GI regarding endoscopy.
—Susan Kreimer
Estimating End-of-Life for Hospitalized Patients
Quotes from the Field
We cannot rely solely on a tool to make decisions. The tool is a decision aid.
Alvin H. Moss, MD, FAAHPM
Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown
Predictions really apply to groups of people, not individuals.
J. Randall Curtis, MD, MPH
Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle
if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.
JoAnn Wood, MD, MSEd, MHA
Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock
Patients feel that you’re almost abandoning them, that there’s something you’re withholding.
Ann Sheehy
Director of the hospitalist service at University of Wisconsin Medical Center in Madison
Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.
David Casarett, MD, MA
Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia
End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.
“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”
Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.
Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”
Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.
“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”
But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.
“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.
“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.
More Medical Tests and Procedures
In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.1
“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”
The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.1
As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.
“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.
What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says.
End-of-Life Conversations
By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.2
“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”
Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.
Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.
“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”
Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.
While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”
Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”
When Doing Less Is More
End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”
In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.3 What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.4,5
Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.
About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.
Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.
—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha
Planning Ahead
In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.
“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.
Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.1
“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.
Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.
Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”
Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).
—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center
Educating the Public
End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”
When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.
“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”
Susan Kreimer is a freelance medical writer based in New York.
Helpful End-of-Life Prediction Tools
APACHE II (Acute Physiology and Chronic Health Evaluation II)
A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx
SOFA (Sequential Organ Failure Assessment)
SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html
The Karnofsky Performance Scale Index
This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html
PPS (Palliative Performance Scale)
First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/
The BODE Index
BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm
The Charlson Comorbidity Index
This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php
Hemodialysis Mortality Predictor
This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq
—Susan Kreimer
References
- Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
- Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
- Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
- Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
- Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.
Quotes from the Field
We cannot rely solely on a tool to make decisions. The tool is a decision aid.
Alvin H. Moss, MD, FAAHPM
Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown
Predictions really apply to groups of people, not individuals.
J. Randall Curtis, MD, MPH
Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle
if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.
JoAnn Wood, MD, MSEd, MHA
Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock
Patients feel that you’re almost abandoning them, that there’s something you’re withholding.
Ann Sheehy
Director of the hospitalist service at University of Wisconsin Medical Center in Madison
Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.
David Casarett, MD, MA
Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia
End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.
“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”
Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.
Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”
Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.
“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”
But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.
“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.
“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.
More Medical Tests and Procedures
In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.1
“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”
The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.1
As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.
“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.
What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says.
End-of-Life Conversations
By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.2
“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”
Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.
Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.
“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”
Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.
While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”
Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”
When Doing Less Is More
End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”
In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.3 What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.4,5
Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.
About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.
Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.
—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha
Planning Ahead
In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.
“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.
Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.1
“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.
Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.
Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”
Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).
—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center
Educating the Public
End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”
When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.
“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”
Susan Kreimer is a freelance medical writer based in New York.
Helpful End-of-Life Prediction Tools
APACHE II (Acute Physiology and Chronic Health Evaluation II)
A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx
SOFA (Sequential Organ Failure Assessment)
SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html
The Karnofsky Performance Scale Index
This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html
PPS (Palliative Performance Scale)
First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/
The BODE Index
BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm
The Charlson Comorbidity Index
This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php
Hemodialysis Mortality Predictor
This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq
—Susan Kreimer
References
- Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
- Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
- Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
- Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
- Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.
Quotes from the Field
We cannot rely solely on a tool to make decisions. The tool is a decision aid.
Alvin H. Moss, MD, FAAHPM
Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown
Predictions really apply to groups of people, not individuals.
J. Randall Curtis, MD, MPH
Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle
if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.
JoAnn Wood, MD, MSEd, MHA
Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock
Patients feel that you’re almost abandoning them, that there’s something you’re withholding.
Ann Sheehy
Director of the hospitalist service at University of Wisconsin Medical Center in Madison
Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.
David Casarett, MD, MA
Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia
End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.
“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”
Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.
Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”
Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.
“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”
But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.
“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.
“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.
More Medical Tests and Procedures
In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.1
“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”
The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.1
As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.
“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.
What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says.
End-of-Life Conversations
By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.2
“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”
Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.
Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.
“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”
Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.
While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”
Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”
When Doing Less Is More
End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”
In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.3 What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.4,5
Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.
About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.
Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.
—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha
Planning Ahead
In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.
“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.
Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.1
“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.
Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.
Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”
Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).
—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center
Educating the Public
End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”
When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.
“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”
Susan Kreimer is a freelance medical writer based in New York.
Helpful End-of-Life Prediction Tools
APACHE II (Acute Physiology and Chronic Health Evaluation II)
A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx
SOFA (Sequential Organ Failure Assessment)
SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html
The Karnofsky Performance Scale Index
This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html
PPS (Palliative Performance Scale)
First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/
The BODE Index
BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm
The Charlson Comorbidity Index
This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php
Hemodialysis Mortality Predictor
This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq
—Susan Kreimer
References
- Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
- Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
- Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
- Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
- Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.
Videoconferencing in Medical Settings Takes Off
Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.
Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.
Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jonathan D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.
Advantages and Challenges
Remote patient monitoring in intensive-care units is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.1
In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.
Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.
Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.
—Jonathan D. Linkous, CEO, American Telemedicine Association
When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”
Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.
“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.
Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.
Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.
“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”
Moving Ahead
As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.
The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.
IPC’s hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”
Susan Kreimer is a freelance medical writer based in New York.
References
Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.
Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.
Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jonathan D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.
Advantages and Challenges
Remote patient monitoring in intensive-care units is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.1
In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.
Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.
Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.
—Jonathan D. Linkous, CEO, American Telemedicine Association
When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”
Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.
“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.
Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.
Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.
“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”
Moving Ahead
As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.
The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.
IPC’s hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”
Susan Kreimer is a freelance medical writer based in New York.
References
Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.
Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.
Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jonathan D. Linkous, CEO of the American Telemedicine Association in Washington, D.C. About 60 specialities and subspecialties—from mental health to wound care—rely on telemedicine.
Advantages and Challenges
Remote patient monitoring in intensive-care units is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.1
In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.
Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.
Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.
—Jonathan D. Linkous, CEO, American Telemedicine Association
When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”
Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.
“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.
Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.
Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.
“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”
Moving Ahead
As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.
The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.
IPC’s hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”
Susan Kreimer is a freelance medical writer based in New York.
References
Tech Takes Off: Videoconferences in medical settings is more acceptable and affordable, but hurdles remain
Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.
Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.
Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona
Advantages and Challenges
Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.1
In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.
Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.
—Matthew Harbison, MD, medical director, Sound Physicians hospitalist services, Memorial Hermann-Texas Medical Center
Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.
When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”
Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.
“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.
Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.
—Jonathan D. Linkous, CEO, American Telemedicine Association
Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.
“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”
Moving Ahead
As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.
The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.
IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”
Susan Kreimer is a freelance medical writer based in New York.
Reference
1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.
Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.
Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.
Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona
Advantages and Challenges
Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.1
In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.
Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.
—Matthew Harbison, MD, medical director, Sound Physicians hospitalist services, Memorial Hermann-Texas Medical Center
Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.
When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”
Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.
“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.
Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.
—Jonathan D. Linkous, CEO, American Telemedicine Association
Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.
“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”
Moving Ahead
As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.
The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.
IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”
Susan Kreimer is a freelance medical writer based in New York.
Reference
1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.
Picture this likely scenario: You’re a hospitalist in a remote setting, and a patient with stroke symptoms is rushed in by ambulance. Numbness has overcome one side of his body. Dizziness disrupts his balance, his speech becomes slurred, and his vision is blurred. Treatment must be started swiftly to halt irreversible brain damage. The nearest neurologist is located hours away, but thanks to advanced video technology, you’re able to instantly consult face to face with that specialist to help ensure optimal recovery for the patient.
Such applications of telemedicine are becoming more mainstream and affordable, facilitating discussions and decisions between healthcare providers while improving patient access to specialty care in emergencies and other situations.
Remote hospitalist services include videoconferencing for patient monitoring and assessment of various clinical services, says Jona
Advantages and Challenges
Remote patient monitoring in ICUs is on the upswing, filling gaps in the shortage of physicians specializing in critical care. Some unit administrators have established off-site command centers for these specialists to follow multiple facilities with the assistance of video technology and to intervene at urgent times.1
In a neonatal ICU, this type of live-feed technology allows for a face-to-face interaction with a pediatric pulmonologist, for example, when a premature infant is exhibiting symptoms of respiratory distress in the middle of the night, says David Cattell-Gordon, MSW, director of the Office of Telemedicine at the University of Virginia in Charlottesville.
Similarly, in rural areas where women don’t have immediate access to high-risk obstetricians, telemedicine makes it possible to consult with maternal-fetal medicine specialists from a distance, boosting the chances for pregnant mothers with complex conditions to carry healthy babies to term, says Cattell-Gordon. “Our approach has been to bring telemedicine to hospitals and clinics in communities where that resource [specialists] otherwise is unavailable,” he adds.
—Matthew Harbison, MD, medical director, Sound Physicians hospitalist services, Memorial Hermann-Texas Medical Center
Compared with telephone conversations, the advantages of video consultations are multifold: They display a patient’s facial expressions, gestures, and other body language, which might assist with the diagnosis and prescribed treatment, says Kerry Weiner, MD, chief clinical officer for IPC: The Hospitalist Company in North Hollywood, Calif., which has a presence in about 900 facilities in 25 states.
When the strength of that assessment depends on visual inspection, the technology can be particularly helpful. “The weak part of it is when you need to touch” to guide that assessment, Dr. Weiner says. That’s when the technology isn’t as useful. Still, he adds, “We use teleconferencing all over the place in a Skype-like manner, only more sophisticated. It’s more encrypted.”
Interacting within a secure network is crucial to protect privacy, says Peter Kragel, MD, clinical director of the Telemedicine Center at East Carolina University’s Brody School of Medicine in Greenville, N.C. As with any form of communication that transmits identifiable patient information, healthcare providers must comply with HIPAA guidelines when employing videoconferencing services similar to Skype.
“Because of concerns about compliance with encryption and confidentiality regulations, we do not use [videoconferencing] here,” Dr. Kragel says.
Additionally, “telemedicine isn’t always appropriate for patient care,” Linkous says. “All of this depends on the circumstances and needs of the patient. Obviously, surgery requires a direct physician-patient interaction, except for robotic surgery.” For hospitals that don’t have any neurology coverage, telemedicine robots can assist with outside consults for time-sensitive stroke care.
—Jonathan D. Linkous, CEO, American Telemedicine Association
Videoconferencing isn’t necessary for all telemedicine encounters, Linkous says. Teledermatology and retinal screening use “store and forward” communication of images, which allows for the electronic transmission of images and documents in non-emergent situations in which immediate video isn’t necessary.
“As a society, we’ve become more comfortable with the technology,” says Matthew Harbison, MD, medical director of Sound Physicians hospitalist services at Memorial Hermann-Texas Medical Center in Houston. “And as the technology continues to develop, ultimately there will be [more of] a role, but how large that will be is difficult to predict.” He adds that “the advantages are obviously in low-staffed places or staffing-challenged sites.”
Moving Ahead
As experts continue to iron out the kinks and as communities obtain greater access to broadband signals, telemedicine equipment is moving to advanced high-definition platforms. Meanwhile, the expense has come down considerably since its inception in the mid-1990s. A high-definition setup that once cost upward of $130,000 is now available for less than $10,000, Cattell-Gordon says.
The digital transmission also can assist in patient follow-up after discharge from the hospital and in monitoring various chronic diseases from home. It’s an effective tool for medical staff meetings and training purposes as well.
IPC's hospitalists have been using the technology to communicate with each other, brainstorming across regions of the country. “Because we’re a national company,” Dr. Weiner says, “this has changed the game in terms of being able to collaborate.”
Susan Kreimer is a freelance medical writer based in New York.
Reference
1. Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671-2678.
ONLINE EXCLUSIVE: Med-Peds Physicians Make their Mark
Every day in the life of an internist and pediatrician, clinical questions arise. For HM practitioners, treating patients with chronic illnesses who are also on the cusp of adulthood presents a new set of challenges.
That’s when physicians trained in both internal medicine and pediatrics (med-peds) can lend their expertise. Once a physician successfully completes a four-year combined med-peds residency program, he or she may take the board certification exams in both internal medicine and pediatrics. Med-peds programs are now accredited by the Accreditation Council for Graduate Medical Education (ACGME) as a combined program instead of separate accreditation in internal medicine and pediatrics.
“The best solution would be to have more med-peds specialists as hospitalists,” says Moises Auron, MD, an assistant professor of medicine and pediatrics at Cleveland Clinic. They “can facilitate the transition by identifying these patients and providing an increased sensibility to the pediatric provider to ‘let the patient go’ and to open new insights to the adult providers to welcome those patients,” he says.
Broad-Based Training
—Moises Auron, MD, assistant professor of medicine and pediatrics, Cleveland Clinic
A med-peds physician can care for people of all ages—from newborns to geriatric patients. He or she is prepared for the demands of private practice, academic medicine, hospitalist programs, and fellowships, according to the National Med-Peds Residents’ Association.
While med-peds residency offers exceptional training for primary care, it also leaves open the option of pursuing a subspecialty in either internal medicine or pediatrics, or both. Subspecialties include cardiology, infectious disease, pulmonary/critical care, women’s health, and sports medicine.
Med-peds celebrated its 40th anniversary as a formal training option in 2007. There are currently about 1,400 med-peds residents in training and about 6,300 med-peds physicians in practice, according to the American Academy of Pediatrics’ section on med-peds.
This broad-based training helps ensure smoother transitions of care. “It’s incumbent upon adult physicians to make the pediatric physicians aware of what services they offer, and also for the pediatricians to reach out with specific patients and refer them to adult physicians,” says W. Benjamin Rothwell, MD, associate program director of the med-peds residency at Tulane University School of Medicine in New Orleans.
Susan Kreimer is a freelance medical writer based in New York.
Every day in the life of an internist and pediatrician, clinical questions arise. For HM practitioners, treating patients with chronic illnesses who are also on the cusp of adulthood presents a new set of challenges.
That’s when physicians trained in both internal medicine and pediatrics (med-peds) can lend their expertise. Once a physician successfully completes a four-year combined med-peds residency program, he or she may take the board certification exams in both internal medicine and pediatrics. Med-peds programs are now accredited by the Accreditation Council for Graduate Medical Education (ACGME) as a combined program instead of separate accreditation in internal medicine and pediatrics.
“The best solution would be to have more med-peds specialists as hospitalists,” says Moises Auron, MD, an assistant professor of medicine and pediatrics at Cleveland Clinic. They “can facilitate the transition by identifying these patients and providing an increased sensibility to the pediatric provider to ‘let the patient go’ and to open new insights to the adult providers to welcome those patients,” he says.
Broad-Based Training
—Moises Auron, MD, assistant professor of medicine and pediatrics, Cleveland Clinic
A med-peds physician can care for people of all ages—from newborns to geriatric patients. He or she is prepared for the demands of private practice, academic medicine, hospitalist programs, and fellowships, according to the National Med-Peds Residents’ Association.
While med-peds residency offers exceptional training for primary care, it also leaves open the option of pursuing a subspecialty in either internal medicine or pediatrics, or both. Subspecialties include cardiology, infectious disease, pulmonary/critical care, women’s health, and sports medicine.
Med-peds celebrated its 40th anniversary as a formal training option in 2007. There are currently about 1,400 med-peds residents in training and about 6,300 med-peds physicians in practice, according to the American Academy of Pediatrics’ section on med-peds.
This broad-based training helps ensure smoother transitions of care. “It’s incumbent upon adult physicians to make the pediatric physicians aware of what services they offer, and also for the pediatricians to reach out with specific patients and refer them to adult physicians,” says W. Benjamin Rothwell, MD, associate program director of the med-peds residency at Tulane University School of Medicine in New Orleans.
Susan Kreimer is a freelance medical writer based in New York.
Every day in the life of an internist and pediatrician, clinical questions arise. For HM practitioners, treating patients with chronic illnesses who are also on the cusp of adulthood presents a new set of challenges.
That’s when physicians trained in both internal medicine and pediatrics (med-peds) can lend their expertise. Once a physician successfully completes a four-year combined med-peds residency program, he or she may take the board certification exams in both internal medicine and pediatrics. Med-peds programs are now accredited by the Accreditation Council for Graduate Medical Education (ACGME) as a combined program instead of separate accreditation in internal medicine and pediatrics.
“The best solution would be to have more med-peds specialists as hospitalists,” says Moises Auron, MD, an assistant professor of medicine and pediatrics at Cleveland Clinic. They “can facilitate the transition by identifying these patients and providing an increased sensibility to the pediatric provider to ‘let the patient go’ and to open new insights to the adult providers to welcome those patients,” he says.
Broad-Based Training
—Moises Auron, MD, assistant professor of medicine and pediatrics, Cleveland Clinic
A med-peds physician can care for people of all ages—from newborns to geriatric patients. He or she is prepared for the demands of private practice, academic medicine, hospitalist programs, and fellowships, according to the National Med-Peds Residents’ Association.
While med-peds residency offers exceptional training for primary care, it also leaves open the option of pursuing a subspecialty in either internal medicine or pediatrics, or both. Subspecialties include cardiology, infectious disease, pulmonary/critical care, women’s health, and sports medicine.
Med-peds celebrated its 40th anniversary as a formal training option in 2007. There are currently about 1,400 med-peds residents in training and about 6,300 med-peds physicians in practice, according to the American Academy of Pediatrics’ section on med-peds.
This broad-based training helps ensure smoother transitions of care. “It’s incumbent upon adult physicians to make the pediatric physicians aware of what services they offer, and also for the pediatricians to reach out with specific patients and refer them to adult physicians,” says W. Benjamin Rothwell, MD, associate program director of the med-peds residency at Tulane University School of Medicine in New Orleans.
Susan Kreimer is a freelance medical writer based in New York.
Do Pregnant Teens with Chronic Ailments Make You Nervous?
Pre-existing diabetes, hypertension, and other ongoing conditions are tough enough to manage in children as they blossom into adolescents and then young adults. To make matters more complex, hospitalists on occasion encounter pregnant teenagers with chronic illnesses.
The physicians and nurses on a pediatric floor might not be comfortable with obstetrics, or they might lack the equipment for monitoring fetal heart tones. In such instances, a pregnant teen would be best served in an adult hospital with obstetric services, says Heather Toth, MD, director of the med-peds residency program at the Medical College of Wisconsin in Milwaukee.
At times, however, a non-pediatric hospital might be hard-pressed to find a blood pressure cuff snug enough for a smaller patient. Collaboration between adult and pediatric providers is essential to iron out these types of kinks, Dr. Toth says.
It’s understandable if “internal-medicine hospitalists get nervous about pregnant patients,” says Rob Olson, MD, an OBGYN hospitalist at PeaceHealth St. Joseph Medical Center in Bellingham, Wash., and editor of ObGynHospitalist.com. Because adolescents’ emotions can be more magnified, “you’ve got all the drama of their teen life as well as the complications of the pregnancy.”
Like adult expectant mothers, teens present with pregnancy-related complications, most commonly preeclampsia, as well as premature labor. Gestational diabetes and urinary tract or kidney infections also occur, says Laura Elizabeth Riley, MD, director of labor and delivery at Massachusetts General Hospital in Boston.
“We take care of pregnant teens with medical conditions just as we would adults,” Dr. Riley says, adding that pediatric hospitalists typically don’t get involved in care on a maternity ward.
OBGYNs are in charge of pregnant teens. If complications arise, a maternal fetal medicine specialist would intervene, says Patrice M. Weiss, MD, chair of the Patient Safety and Quality Committee at the American Congress of Obstetricians and Gynecologists.
The degree of a pregnancy complication is related to the severity of a patient’s underlying medical condition. Teen pregnancies already are considered high-risk due to young age, says Dr. Weiss, who is the OBGYN chair and professor at the Carilion Clinic/Virginia Tech Carilion School of Medicine in Roanoke.
Preventing teen pregnancies is the biggest challenge, followed by some expectant mothers’ reluctance to seek prenatal care and keep appointments, says Tod Aeby, MD, generalist division director of obstetrics, gynecology, and women’s health at the University of Hawaii at Manoa’s John A. Burns School of Medicine in Honolulu.
—Laura Elizabeth Riley, MD, director of labor and delivery, Massachusetts General Hospital, Boston
“Parents in denial, angry, or embarrassed about their pregnant teen can also be another barrier to early and consistent care,” Dr. Aeby says.
In his experience, many of the chronic conditions affecting these adolescents fall in the categories of mental health (eating disorders, depression, schizophrenia, bipolar affective disorder) or autoimmune diseases (lupus or Type 1 diabetes). Asthma and obesity also are prevalent in Hawaii, so hospitalists should consider regional factors.
“Many pregnant teens do well with pregnancy—they are young and healthy,” says Dr. Riley of Mass General. “Some have a host of social issues, which can complicate pregnancy, so it is important that their social supports be evaluated prior to discharge with a newborn.”
Pre-existing diabetes, hypertension, and other ongoing conditions are tough enough to manage in children as they blossom into adolescents and then young adults. To make matters more complex, hospitalists on occasion encounter pregnant teenagers with chronic illnesses.
The physicians and nurses on a pediatric floor might not be comfortable with obstetrics, or they might lack the equipment for monitoring fetal heart tones. In such instances, a pregnant teen would be best served in an adult hospital with obstetric services, says Heather Toth, MD, director of the med-peds residency program at the Medical College of Wisconsin in Milwaukee.
At times, however, a non-pediatric hospital might be hard-pressed to find a blood pressure cuff snug enough for a smaller patient. Collaboration between adult and pediatric providers is essential to iron out these types of kinks, Dr. Toth says.
It’s understandable if “internal-medicine hospitalists get nervous about pregnant patients,” says Rob Olson, MD, an OBGYN hospitalist at PeaceHealth St. Joseph Medical Center in Bellingham, Wash., and editor of ObGynHospitalist.com. Because adolescents’ emotions can be more magnified, “you’ve got all the drama of their teen life as well as the complications of the pregnancy.”
Like adult expectant mothers, teens present with pregnancy-related complications, most commonly preeclampsia, as well as premature labor. Gestational diabetes and urinary tract or kidney infections also occur, says Laura Elizabeth Riley, MD, director of labor and delivery at Massachusetts General Hospital in Boston.
“We take care of pregnant teens with medical conditions just as we would adults,” Dr. Riley says, adding that pediatric hospitalists typically don’t get involved in care on a maternity ward.
OBGYNs are in charge of pregnant teens. If complications arise, a maternal fetal medicine specialist would intervene, says Patrice M. Weiss, MD, chair of the Patient Safety and Quality Committee at the American Congress of Obstetricians and Gynecologists.
The degree of a pregnancy complication is related to the severity of a patient’s underlying medical condition. Teen pregnancies already are considered high-risk due to young age, says Dr. Weiss, who is the OBGYN chair and professor at the Carilion Clinic/Virginia Tech Carilion School of Medicine in Roanoke.
Preventing teen pregnancies is the biggest challenge, followed by some expectant mothers’ reluctance to seek prenatal care and keep appointments, says Tod Aeby, MD, generalist division director of obstetrics, gynecology, and women’s health at the University of Hawaii at Manoa’s John A. Burns School of Medicine in Honolulu.
—Laura Elizabeth Riley, MD, director of labor and delivery, Massachusetts General Hospital, Boston
“Parents in denial, angry, or embarrassed about their pregnant teen can also be another barrier to early and consistent care,” Dr. Aeby says.
In his experience, many of the chronic conditions affecting these adolescents fall in the categories of mental health (eating disorders, depression, schizophrenia, bipolar affective disorder) or autoimmune diseases (lupus or Type 1 diabetes). Asthma and obesity also are prevalent in Hawaii, so hospitalists should consider regional factors.
“Many pregnant teens do well with pregnancy—they are young and healthy,” says Dr. Riley of Mass General. “Some have a host of social issues, which can complicate pregnancy, so it is important that their social supports be evaluated prior to discharge with a newborn.”
Pre-existing diabetes, hypertension, and other ongoing conditions are tough enough to manage in children as they blossom into adolescents and then young adults. To make matters more complex, hospitalists on occasion encounter pregnant teenagers with chronic illnesses.
The physicians and nurses on a pediatric floor might not be comfortable with obstetrics, or they might lack the equipment for monitoring fetal heart tones. In such instances, a pregnant teen would be best served in an adult hospital with obstetric services, says Heather Toth, MD, director of the med-peds residency program at the Medical College of Wisconsin in Milwaukee.
At times, however, a non-pediatric hospital might be hard-pressed to find a blood pressure cuff snug enough for a smaller patient. Collaboration between adult and pediatric providers is essential to iron out these types of kinks, Dr. Toth says.
It’s understandable if “internal-medicine hospitalists get nervous about pregnant patients,” says Rob Olson, MD, an OBGYN hospitalist at PeaceHealth St. Joseph Medical Center in Bellingham, Wash., and editor of ObGynHospitalist.com. Because adolescents’ emotions can be more magnified, “you’ve got all the drama of their teen life as well as the complications of the pregnancy.”
Like adult expectant mothers, teens present with pregnancy-related complications, most commonly preeclampsia, as well as premature labor. Gestational diabetes and urinary tract or kidney infections also occur, says Laura Elizabeth Riley, MD, director of labor and delivery at Massachusetts General Hospital in Boston.
“We take care of pregnant teens with medical conditions just as we would adults,” Dr. Riley says, adding that pediatric hospitalists typically don’t get involved in care on a maternity ward.
OBGYNs are in charge of pregnant teens. If complications arise, a maternal fetal medicine specialist would intervene, says Patrice M. Weiss, MD, chair of the Patient Safety and Quality Committee at the American Congress of Obstetricians and Gynecologists.
The degree of a pregnancy complication is related to the severity of a patient’s underlying medical condition. Teen pregnancies already are considered high-risk due to young age, says Dr. Weiss, who is the OBGYN chair and professor at the Carilion Clinic/Virginia Tech Carilion School of Medicine in Roanoke.
Preventing teen pregnancies is the biggest challenge, followed by some expectant mothers’ reluctance to seek prenatal care and keep appointments, says Tod Aeby, MD, generalist division director of obstetrics, gynecology, and women’s health at the University of Hawaii at Manoa’s John A. Burns School of Medicine in Honolulu.
—Laura Elizabeth Riley, MD, director of labor and delivery, Massachusetts General Hospital, Boston
“Parents in denial, angry, or embarrassed about their pregnant teen can also be another barrier to early and consistent care,” Dr. Aeby says.
In his experience, many of the chronic conditions affecting these adolescents fall in the categories of mental health (eating disorders, depression, schizophrenia, bipolar affective disorder) or autoimmune diseases (lupus or Type 1 diabetes). Asthma and obesity also are prevalent in Hawaii, so hospitalists should consider regional factors.
“Many pregnant teens do well with pregnancy—they are young and healthy,” says Dr. Riley of Mass General. “Some have a host of social issues, which can complicate pregnancy, so it is important that their social supports be evaluated prior to discharge with a newborn.”