Crash Cart: AHCA provisions, lab results via smartphones, and dogs in the ED

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This week: The American Health Care Act; smartphones leading to faster discharges; dogs helping patients wag more, bark less. Join in as our editors discuss the week’s headlines.


The American Health Care Act and the emergency department

ABC lists the major provisions of AHCA, explaining the details and highlighting the differences between it and ACA (Obamacare). Original Article by ABC News.

Nicholas Genes, MD, PhD: I’m glad we’re finally talking about the AHCA, even though it seems like several atrocities ago. The new version that passed the House in early May wasn’t scored by the CBO and a lot of representatives seemed unclear on its implications, even as they were voting for it. But pretty much every policy expert thinks it’s worse for lower- and middle-income Americans than the version that was debated in March (the bill remains a good deal for very wealthy Americans). I’ve been in ACEP for more than a decade, and can’t remember them taking a stand against a bill like they did against the AHCA: “The Affordable Care Act included emergency services as an essential health benefit and any replacement legislation must do the same.  Patients can’t choose where and when they will need emergency care and they shouldn’t be punished financially for having emergencies… If the House chooses to eliminate the mandatory coverage of emergency medical care by health insurance plans — which currently exists under the Affordable Care Act — ACEP would have to oppose the bill.” 

Seth Trueger, MD, MPH: I’m not going to pretend that the ACA is perfect — far from it. But big laws like this used to get technical fixes and other adjustments as the kinks got identified. Instead of fixing the family glitch, subsidy cliff, etc, the GOP Congress dug in their heels and is now trying to pass a law that will make everything worse for pretty much every stakeholder, except wealthy people (including, very specifically, insurance company executives) who will get tax cuts. Compare ordering a burger and it coming out a little undercooked — the answer isn’t to burn down the restaurant. It’s no surprise that every stakeholder group (patients, hospitals, physicians, nurses) is against the AHCA, and you could not make up the hypocrisy and procedural shenanigans they used to pass the House.

E. Paul DeKoning, MD, MS: I am in no way a policy wonk and I don’t envy the task of “fixing” healthcare. One of my biggest gripes with Obamacare from the start was the individual mandate. I personally don’t feel the government should be in the healthcare business. At the same time, I have a problem with the thinking by many that we as consumers shouldn’t have to pay for anything–I’m just entitled to it. Healthcare is expensive–too expensive, I get that. I do wish that the this bill would have dealt with portability of insurance across state lines. Free market competition is a good thing. Clearly, more work needs to be done. So, let’s do it and not demonize those trying to do just that, even (and especially) when we disagree with them.

William Sullivan, DO, JD: Nice article. Provides a nice summary of the similarities and differences in the laws. A few comments on the changes, though. Ends individual mandate. It wasn’t working anyway. A surcharge for coverage lapse is a good idea, but it doesn’t go far enough. People with catastrophic illness would still be able to game the system and purchase insurance after being diagnosed – kind of like purchasing fire insurance while your house is burning. Or purchasing lottery tickets after the numbers have been drawn. We should just have a single cut-off date for purchasing policies where everyone gets coverage for all conditions. After that, insurers should have the ability to deny coverage (or add premiums) for pre-existing conditions. This is the way it worked pre-Obamacare. Medicaid work requirement. This is a bad thing for able-bodied adults? Higher premiums for older people. Already occurs in Obamacare. Stop the sensationalism. This is a reflection of risk. Older people are generally sicker people. Just got whacked for auto insurance premiums for my 16 year old son. Why are his premiums so much higher than mine? Traditionally young males get into more accidents. This isn’t rocket science. Essential health benefits. I have little doubt that emergency medical care will be covered. If not, then people will just purchase a different policy. Funny thing how the free market works. Seth, the ACA was enacted more than 7 years ago. In that time, we’ve seen how we really can’t “keep our own doctor” like we did before Obamacare, how people who needed medical care were forced to purchase insurance that often didn’t cover that care, how insurance premiums have exploded, how deductibles have skyrocketed – thereby making many patients functionally uninsured, and how insurers are pulling out of markets all over the country. Here’s an article from today showing how “insurance is hanging by a thread” in two states. You said before that “perfect can’t be the enemy of good,” but seven years have shown us that the ACA isn’t even “good.” It isn’t an “undercooked burger,” it’s rancid meat with crawling bugs. Maybe we don’t burn the restaurant to the ground for serving the food, but we sure as heck close it down rather than letting it poison everyone for seven years. And at least the shenanigans in the current administration didn’t involve the most prominent member of the legislature telling the public that we “have to pass the bill so you can find out what is in it.” How soon we forget…

Seth Trueger, MD, MPH: Bill — you said ” This is the way it worked pre-Obamacare” which says it all.

E. Paul DeKoning, MD, MS: This is a bigger issue for me because it’s not in the constitutionally-mandated function of the US government to provide healthcare or mandate insurance. America is, by its very founding, different from the rest of the world. It is in the nature our very founding that makes us exceptional and what makes us unique as a people. I don’t assume that what is best for the rest of the world is best for us; neither should the government assume what is best for me or you. The government actually doesn’t know best (let alone what is cheapest). I think the free-market, when given the opportunity to do provide it, and a free citizen when given the liberty to choose it, can do a better job. Those are both huge “ifs”, to be sure, and demands responsibility on both ends, but doesn’t mean they aren’t ideals worth pursuing. That is not contradictory to a nation’s feeling that “keeping their citizens healthy (and productive) via universal healthcare is in the country’s best interest.” These aren’t mutually exclusive pursuits. It might actually be better by freeing the market and the people–truly freeing them. Now that truly is in the country’s best interest.

Seth Trueger, MD, MPH: Paul- should we eliminate EMTALA? Because unless we give hospitals the power to turn poor people away and we are happy with the consequences, we are all on health care financing together.

E. Paul DeKoning, MD, MS: Nope, not saying that at all. I’m not talking about charity care for the poor. A benevolent society cares for the poor, the elderly, those less fortunate. I actually think we as a society can do both. I simply don’t like being told by the government that I’m required to purchase something, at prices fixed by them, enforced by the IRS, and then lied to about what it is that I’m actually purchasing. I just don’t think the government should be in the health insurance business.

Seth Trueger, MD, MPH: I don’t think I can put it better than this:

William Sullivan, DO, JD: #1. We can find redeeming qualities in just about anything. Doing so doesn’t make it good. Your rancidburger may be served on the best tasting bun ever. And it could cost half as much as all the other burgers in town. Doesn’t mean that anyone would want to eat it – or that the government should be forcing it down our throats because it’s supposedly good for us. #2. The cartoon seems to suggest that if we get rid of a failing government health program, we are then prohibited from using any of the potentially good ideas within that program. Who has ever raised that proposition (see “strawman argument“)? If we keep the few good aspects of Obamacare but delete all of the bad aspects of Obamacare, it probably isn’t Obamacare any longer. You can’t disassemble a sinking boat and then point at the pile of lumber and call it a boat. Maybe the components of the boat get repurposed into something different like part of a house, or into a much better boat – one that actually floats … and that people actually want to ride in. But arguing that we should keep a sinking boat because it has a nice hull and a cool captain’s wheel, well, you get the picture.

Seth Trueger, MD, MPH: “Who has ever raised that proposition”? The House of Representatives.

E. Paul DeKoning, MD, MS: Everyone stay calm. I’m from the government. I’m here to help.

Seth Trueger, MD, MPH: “If you think government healthcare is bad, wait until Comcast runs it.”

Nicholas Genes, MD, PhD: I realized a long time ago I don’t have the zeal to debate anti-vaxxers or creationists – even those that are arguing in good faith have such different underpinnings in their worldview, I end up just feeling profoundly alienated. Lately I’m feeling the same way, when the glory of the free market and the Constitution come up in conversation. Look – free markets and the Constitution are both wonderful, and have made a lot of great things possible. But they’ve also been responsible for some terrible things, too. Smart people ought to be able to come together and make protections, or amendments, to improve things. It’s not always straightforward, and there could be unintended consequences, but sometimes it’s worth trying something, right? Free markets have given us wonderful technology and efficiency and abundance, but left unregulated tends towards monopoly, and stagnation, and abuse. This is not controversial. And there’s nothing in the Constitution about education, or interstate highways, or moon landings, but hopefully we can agree we’re better off that the government played a role in those areas. We can still think America is exceptional, while not shutting our minds to how other countries have handled their own problems. If we can’t agree on this then we’re not going to have a productive conversation about high risk pools or essential benefits.


Sending lab results to physicians by smartphone can result in faster discharges

A study in Annals of Emergency medicine shows chest pain patients whose physicians received troponin results via smartphone spent about 26 minutes less waiting to be discharged, and the researchers believe the same can apply with other medical alerts. Original Article by EurekAlert.

Nicholas Genes, MD, PhD: Having select lab results come to a physician’s phone – yes! This is an idea whose time has come. Actually this is long overdue – somehow we’ve accepted that I can track my shipments and my Uber faster and easier than I can track a patients’ progress through the ED. We just have to be smart about how we implement smartphone notifications, and avoid the mistakes and CYA-mentality that led to alert fatigue and excessive clicking in desktop EHRs.

Jyoti Mahapatra, MD: Great point Nick. I can have sushi ordered and delivered to my home or buy a car on Amazon quicker than I can get a d-dimer. I imagine checking results while suturing a patient and then asking my nurses to page a consultant, obtain discharge vitals, or draw up a vial of Bicillin while I never have to stop my procedure. This would be fantastic for ED flow as long as it didn’t become yet another interruption during our shifts, or another form of redundancy if we end up having to click acknowledgement of results on a phone AND our EMR.

Ryan McKennon, DO: There is a great opportunity here. I don’t see its use as much in decreasing time to discharge as a more rapid way to obtain critical results and act on them. As noted in the study, time to discharge decision was 26 minutes lower but overall length of stay did not achieve statistical significance (trend towards shorter LOS though). Where I see this being very useful is in critical results; but only if it done correctly. If designed with the end users (us) in mind *gasp* this could avoid the alarm fatigue Nick spoke of. This should not be used by risk management, lab, nursing, or other entities to mark the “physician notified” check box. Could you imagine if there was not an mandatory standard and docs could customize this the way they wanted *another gasp*? No, I don’t want a text on my phone because a patients K+ is 3.4, but less than 2.0, ya, go ahead and blow up my phone. I don’t want to me interrupted doing a central line because a Hb is 9.5, unless that is a 4 gram drop in the last two weeks. Every doc has a different threshold for things they want to be interrupted for. Done correctly, this modality could decrease the time to intervention for a variety of conditions. Very exciting!

E. Paul DeKoning, MD, MS: I’ll pass on this one. I get way too many push alerts, etc and the last thing I need is to have to stop my interview with Mrs. Jones in room 4, go find my Therapy Wallaby and retrieve my phone to see that critical value for Mr. Smith in room 13. That interferes with the care that Mr Smith is getting. I’m no longer “present.” It’s the era of pagers in a different form. Plus, there’s the risk of notification fatigue already mentioned–those critical values will simply be buried in the myriad of other non-critical (read normal) critical value alerts. My lab currently calls me with every NORMAL tylenol level. It took considerable effort to get called about troponins.

William Sullivan, DO, JD: I think that there may be issues of unintended consequences with such a system. How will care for one patient be affected if a doctor is repeatedly distracted by phone messages with another patient’s lab results? If a doctor’s phone is set to receive some messages, what about all the other messages such as e-mails, texts, and Twitter notifications? Heck, I can’t even clean out my e-mail box. What if the smart phone doesn’t get a signal in the ED? What about HIPAA and security issues? How will they implement tracking logs as required under HIPAA? Just because we’re capable of implementing a technology doesn’t mean that we *should* implement that technology. I’m with Paul. I pass on this idea.

Nicholas Genes, MD, PhD: Epic’s implementation of this (which they call “ticklers”) seems particularly clever and well-thought out (despite the name), and may address your concerns. Basically if you’ve installed Epic’s Haiku app on your phone, or Limerick on your Apple Watch, every time you order a lab you can specify whether you want to be tickled when it’s resulted. So, it’s secure, and you get to decide which troponin (or dimer, or CT scan) buzzes your phone. I’m excited we’re getting this feature in a few months – will keep you posted.


Rest and relief for doctor’s and patients in the ED, courtesy of man’s best friend

Dr. Erika Kube shares how OhioHealth’s “Love on a Leash” program is making for happier hospitals. Both patients and physicians report less stress, among other benefits. Original Article by The Columbus Dispatch.

Nicholas Genes, MD, PhD: I love this idea. Affection from the therapy dog is probably a lot more effective, and cheaper, than other remedies we use in the ED – and sometimes it’s just what the patient or staff is looking for. The article notes that the pets are clean and vaccinated, and CDC hasn’t (yet) heard of an infection. No word on allergic reactions. I hope this idea spreads but can’t help but think of those notorious killjoys at The Joint Commission – which I’m told has cited hospitals for plants, and holiday decorations. While I can’t find their criteria online (why be transparent when you can charge for preparatory services?) it seems that plants can trigger allergies and decorations can be a fire hazard – hopefully a well-run therapy dog program can escape TJC’s notice.

Jyoti Mahapatra, MD: In my residency, law enforcement officials would regularly walk the halls of the ED with their K-9 partners. They were fierce german shepards who were there to detect drugs and keep the peace, not as press ganey representatives. But their love for praise and affection made us all smile and feel a little safer. I echo Nick’s concern that the Joint Commission could ruin this, but I hope not. Every ED could use a morale boost, and for those of us working single coverage, small EDs without security, the added benefit of feeling even a little more secure would be great for everyone’s professional attitude.  Maybe we could even train Lassie to bring blankets and sprite to patients, freeing our nurses to collect the urine sample we have been waiting 2 hours for, and then we could dispo patients faster with our smartphone alerts. This will revolutionize emergency medicine! I am bringing some Beggin’ Strips to my next shift and keeping my fingers crossed.

Ryan McKennon, DO: Here is how you get JC’s approval.  When they come for a site visit, the director takes one step to the side revealing Fido. One ear up, head tilted to the side, tail wagging. Perfect, good boy! Who is going to say no to that? If that doesn’t work, ask them to explain to little Timmy, the six-year-old in room 5 with leukemia, why Fido can’t come to play anymore because of some asinine regulation.

E. Paul DeKoning, MD, MS: Ok, sure. My bigger issue is when patients bring their pets with them–therapy pets for whatever ails them–that haven’t actually been trained to be nice and not eat children. I had a patient a few months ago who brought her tiny, yippy therapy dog into the ED that nearly got the left foot of fellowship as he nipped at me. Not cool. The 4yr old patient across the hall was fortunately out of reach. What I really want is a Therapy Wallaby. It could carry my phone and ABX guide.

William Sullivan, DO, JD: I love dogs, but also think this is a bad idea. Pet allergies. Dog attacks. Wound contamination. We can’t have food within a blast radius of a room and we’re supposed to use hand sanitizer before and after even poking our head into a room to see how a patient is doing, but now it’s a good idea to bring Marmaduke in to slobber all over patients? The cognitive dissonance with some of these ideas just blows my mind.


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