Monday, August 14, 2017

Why Doctors Use Fax Machines

By Bryan Vartabedian, MD
Pediatrician, Baylor College of Medicine/Texas Children's Hospital

This post originally appeared on 33 Charts.

Image via Abhisek Sarda on Flickr
Last Thursday Twitter carried a query from a Vox journalist about doctors and fax machines. Why do we use them? The response by the health infosphere was predictable: Why can’t doctors just get with the program? And why are they so behind the times?

It’s not that complicated. And it’s not because we don’t read Wired magazine.

EHRs don’t talk to one another. We wish they did. When select notes and labs are needed we fax one another.

Paper doesn’t talk to EHRs. The shrinking number of doctors who have not been absorbed by hospital systems write things about patients on paper. I fax other doctors who don’t use Epic.

Email isn’t secure. The legal wonks can slice and dice this but email isn’t entirely reliable within the letter of the law.

DME companies don’t have EHRs. So they fax me forms and I fax them back.

Silicon Valley’s preoccupation with building expensive-but-hopeless health applications for nervous rich people has left physicians and their overworked staff with fax machines.

Meanwhile we passively criticize doctors for using the only technology that keeps them out of the legal line of fire in a health information world that can’t seem to get it together. As grotesque as all this may seem to the Internet’s armchair critics, the fax machine is how communication around patient care gets done in the absence of anything better.

Instead of questioning doctors about the persistence of the fax machine perhaps we should ask those who have failed to shape the technology to replace it.

Thursday, August 10, 2017

Vaccines During Pregnancy Give Double Shot of Protection

By C. Mary Healy, MD, Houston
Member, TMA Be Wise — Immunize℠ Physician Advisory Panel and TMA Committee on Infectious Diseases

Pregnancy is a happy, exciting time for most women and their families.  Sometimes moms-to-be can be overwhelmed with well-meaning advice to keep her and her baby healthy and happy, including: avoid potentially harmful products (such as alcohol and smoking), take special care around animals, and follow a healthy diet.   Often overlooked, though, is the need for vaccinations to prevent certain infections that may be deadly for mothers and their young babies.

Vaccination against influenza (the flu) and pertussis (whooping cough) during each pregnancy is recommended by the Centers for Disease Control and Prevention (CDC). While many consider flu a mild illness, it can be deadly for pregnant women and babies. Healthy pregnant women, on average, are five times more likely to develop severe complications from the flu that require hospitalization, than non-pregnant women. Some may die.

Their babies also are at risk of complications if they get the flu because they can’t be vaccinated until they are 6 months old. To be fully protected, babies need two doses one month apart, putting them at risk for much of their first year (until that shot series is completed).

Whooping cough generally is a mild, yet annoying illness in adults. However, the disease is deadly in young babies.  Infants under 6months of age have 20 times the risk of getting whooping cough compared with older children and adults, and — unfortunately for them — a high risk of suffering complications. Two-thirds of infants under 6 months who contract whooping cough end up in the hospital, and many suffer severe complications such as apnea (breath-holding), pneumonia, seizures, and brain damage. Some infants die. Since 1990, almost everyone who died from whooping cough in the United States was under 3 months of age.

Fortunately, vaccines for influenza and whooping cough are available for pregnant women. These vaccines allow mothers to develop antibodies against the diseases that protect the mother against the infection and also pass to the baby across the placenta before birth. This means babies are born with high levels of antibodies that may last until they receive their own vaccines in the first months of life, and until their immune systems are better able to respond to the infection. Giving influenza and whooping cough vaccines during pregnancy has been shown to be safe and very effective in preventing infection in mothers and babies; much more effective than if the mother waits to get vaccines after the baby is born.

Influenza vaccine should be given as soon as it is available, to make sure the pregnant woman is protected before the first cases of flu appear. Whooping cough vaccine should be given during the third trimester of pregnancy (between 27-36 weeks), although it is safe to be given at any time.  Giving it in the third trimester ensures antibodies are higher when the baby is born so baby is protected longer. Mothers who do not get these vaccines while pregnant should get them as soon as possible after birth (unless they have previously had the pertussis booster vaccine).

Equally important is that every person who comes in contact with babies (including fathers, grandparents, family members, and caretakers) is up to date on recommended vaccines. Getting the shots at least two weeks before they contact the baby is best to lessen the chance they will become sick and pass the illnesses on to the baby.

Expectant moms should talk to their doctor about getting vaccines during pregnancy. While all pregnant women should get influenza and whooping cough vaccines during every pregnancy, some women may need additional vaccines if they are at higher risk of getting an infection or are traveling to certain areas.

Vaccines save lives and prevent disease, and vaccines during pregnancy can protect two individuals (mother and infant) with a single shot!

Friday, August 4, 2017

Texas Physicians Standing Up for Border Patients

Texas physician leaders are meeting with federal lawmakers and government officials in Edinburg today to discuss critical health care needs and challenges facing communities along the U.S.-Mexico border.

The 12th Annual Border Health Conference is sponsored by the Texas Medical Association (TMA) Border Health Caucus (BHC). The BHC’s mission is to ensure access to care for all patients along the border, and this year’s conference agenda also covers top issues of national importance.

Many of the issues also affect all Texans and Americans, including:

  • Federal health care act reform and the future;
  • Public health threats like arboviral diseases (diseases spread by insects and other arthropods), and public health infrastructure; and
  • Cross-border health issues, because health care knows no boundaries.

Top Texas physicians, and health care, academic, and government leaders, led by BHC Chair Manuel Acosta, MD; BHC Vice Chair Luis Benavides, MD; and TMA President and founding BHC member Carlos J. Cardenas, MD, as well as honorary conference Chair U.S. Rep. Filemon Vela (D-Brownsville) are in Edinburg today to address these critical issues.

Tuesday, August 1, 2017

The Crockett Hospital’s Painful Demise

By Sid Roberts, MD
Lufkin Radiation Oncologist

This article originally appeared on Dr. Roberts' blog. Rural hospital closures, like this one in Crockett, are a disturbing trend in Texas and the nation and threaten access to care for patients in these areas. 

June 30, 2017 was a sad day for Crockett, Texas, our neighbor just 47 miles to the west. Little River Healthcare ended its management affiliation with the Houston County Hospital District that Friday, effectively shuttering the Crockett hospital. Nearly 200 employees are affected by the closure.

The simple sign taped on the front door said, “HOSPITAL CLOSED” and directed people to either call 911 in an emergency or to go to Palestine Regional Medical Center, the closest hospital 39 miles away.*

Though this seemed like a sudden event, in many ways it was a slow death over many years. The 49-bed Crockett hospital – most recently known as Timberlands Healthcare, under the management of Little River Healthcare since April 18, 2016 – had danced with several management partners over the last several years. Little River Healthcare didn’t even last 15 months.

Prior to Little River Healthcare, CHC (Community Hospital Corporation) was brought in June 1, 2015 to run the Crockett hospital for an interim period after the hospital’s messy divorce from East Texas Medical Center (ETMC) in Tyler. ETMC ran the hospital for 10 years. ETMC claimed to have invested $27 million in facility and technology upgrades in Crockett, but for a hospital in the 21st century, that was a paltry amount when spread out over 10 years.

So why didn’t Little River Healthcare succeed?

According to published news reports, Little River Healthcare blamed Blue Cross and Blue Shield for not paying $32 million it was owed; BCBS would not comment. Little River stated that when it took over the Crockett hospital, the hospital had been “cash flow negative for a long time,” but that they thought they could turn it around.

It was a helluva lot to turn around. Payroll alone was $1.5 million per month. To keep the hospital running in its current state would have cost $2.7 million per month. The Houston County Hospital District board had already increased property taxes to the max amount and even borrowed money in an attempt to keep the hospital afloat.

LRH Co-Owner Ryan Downton was quoted as saying, “We came to the conclusion the patient volume just isn’t there in the town anymore.” The problem was not volume; it was reimbursement. You can double or triple the number of patients you see, but if you don’t get paid adequately, you are just digging a deeper hole.

Crockett is a dying town. According to the Census Bureau, its population is around 6,500 and shrinking. 39% of the population is living in poverty. Only half of those 16 years of age and older are employed. A mere 17.2% of the population 25 years and older has a bachelor’s degree or higher (and 22.4% don’t even have a high school diploma). 27.4% of the population under the age of 65 has no health insurance. In today’s medical climate, no hospital can survive with this demographic. No hospital district can squeeze enough taxes and reimbursement out of an uneducated, poverty-stricken, unemployed, and under- or un-insured demographic to keep a hospital afloat.

What happened in Crockett is, unfortunately, not unusual. At least 15 rural hospitals have closed across Texas over the last several years. Dozens of counties in Texas have just a single physician – or none at all.

I grieve for Crockett. My brother and his wife live there. I have had the privilege of treating many dear patients from Crockett over the years. We share a compassionate state representative, Trent Ashby, whose rural upbringing cannot be far from his mind in a situation like this. Trent has said he is “committed to working with all of the involved stakeholders to mitigate the loss of existing jobs and help move forward with a plan to increase access to healthcare in our area of the state.” I don’t doubt it one bit. But to be honest, there’s not much he can do. CHI St. Luke’s Health Memorial Lufkin leadership was over in Crockett even before the closing to assist some with employment, but even they can’t come close to softening the impact of nearly 200 jobs lost.

Ultimately, this falls far too heavily on the shoulders of the local Houston County Hospital District board to find a solution. They can’t pull money out of thin air or tax property any higher. And they certainly can’t get paid for health care when no insurance coverage or safety net exists. I hope the hospital district board can reassess and reallocate resources to focus on providing comprehensive primary care and prevention services to the citizens of Houston County, at a minimum. They also need to strengthen relationships with surrounding regional hospitals to provide higher level of care services where needed.

Those of us outside Houston County need to open our eyes. Without a much deeper, systemic and national change in how we allocate and pay for health care in this country, what just happened in Crockett is going to be replicated in more and more communities around the country. Let’s help Crockett, but don’t think it can’t happen to us.

*Will Johnson, Senior Reporter for the Messenger News in Grapeland, and Caleb Beames with KTRE-TV have done an excellent job reporting on the hospital closure, and I am indebted to them for some of the details and quotes in this column.

Dr. Sid Roberts is a radiation oncologist at the Arthur Temple, Sr. Regional Cancer Center in Lufkin. He is a contributing writer for the Lufkin Daily News and blogs at

Tuesday, July 25, 2017

Swaddle Your Baby in Protection with Vaccines

Elizabeth Knapp, MD, Austin pediatrician
TMA Be Wise — Immunize℠  Physician Advisory Panel member

When we swaddle babies with a folded blanket, we wrap around them three ways: Fold the right side of the blanket over and tuck it under baby, bring the bottom up over baby’s lower half, then fold the left side across to hug them tight. Similarly, vaccines provide three ways we can protect our babies.  

  1. First, we can keep infants safe by making sure the people around them have been vaccinated against illnesses. That protection starts when the pregnant mom gets vaccines during pregnancy, and the expectant father and grandparents get protection before caring for the new infant. 
  2. Another way we protect our babies is by making sure they get their shots on time. 
  3. The third layer of protection comes by making sure we encourage our infant’s caretakers and daycare workers to be vaccinated, as well. 
I’ll detail the importance of each below.

First layer of protection

Expectant parents and others who will be around your baby should get the Tdap vaccine (tetanus, diphtheria, and pertussis combined) — if they have not had it — and flu vaccines, in addition to the standard adult vaccines. Pregnant women should receive the Tdap vaccine to protect against pertussis, or whooping cough, with each pregnancy (see TMA's infographic on whooping cough). A baby often catches whooping cough from a family member or caregiver who doesn’t know they have it because their symptoms can be mild. 

Babies under 2 months of age are too young to receive the pertussis vaccine but can become gravely sick with whooping cough. Infants who get whooping cough may develop a cough so severe their face turns red and they gasp for air. Occasionally, very young babies may even stop breathing because of the whooping cough virus — with no other signs of illness. 

When moms who are pregnant receive the Tdap vaccine’s protection against whooping cough at 27 to 36 weeks of pregnancy, their body develops an immune response that protects their infant starting before birth. In fact, infants born to moms who had the pertussis vaccine are 85 percent less likely to get this fatal illness in the first 2 months of life. 

In Texas, August through March are peak months for influenza, or the flu virus. This virus spreads from one person to another. The flu virus in little babies causes high fever, grumpy mood, and a bad cough — and it can be much more serious, even fatal. Women who are pregnant should receive the flu vaccine to protect their health and give their baby protection. All people who care for young infants should get their flu vaccine as well. Infants under 6 months of age are too young to receive the vaccine, but if the people around them have the vaccine, their chance of getting the flu virus is less. Once babies are 6 months of age or older, they should receive their annual flu vaccine to protect themselves. When parents and caretakers of young babies receive their vaccines, they give their baby the first layer of protection. 

Second layer of protection

As mentioned above, the second layer of protection you can give your baby is to vaccinate them on schedule. Here’s why: Each vaccine infants receive in the typical schedule provides protection against illnesses that can cause young infants to die. If parents delay or space out vaccines, it postpones the baby from developing the full immune protection against that illness, leaving them vulnerable. Babies do not get overwhelmed by “too many” vaccines. In fact, their immune system’s response to a vaccine is extensively studied before it can be approved. Many scientists are involved in studying and establishing the vaccination schedule to give babies the most effective protection as early as possible. That’s why doctors urge parents to get vaccines on time to protect their babies when they are most vulnerable to these diseases.

Third layer of protection

Finally, that third layer of protection: Ensuring childcare workers are vaccinated. Although people in the health care fields, such as doctors and nurses, are often mandated to have vaccine protection, no such regulation is in place for childcare workers. As parents and child advocates, we can ask about vaccines in our childcare workers. All childcare workers should have protection against whooping cough from the Tdap vaccine and protection against influenza from the flu vaccine. They also should have received all the vaccines required for adults in the United States, including mumps and measles. To learn more and educate childcare workers you see, check out TMA’s childcare worker vaccination infographic.

Our babies are only young and vulnerable for a short time. As parents and child advocates, we need to keep the swaddle of protection wrapped around each of our babies. Only with the three levels of vaccine protection will we be doing all we can to keep each infant healthy and safe. 

Thursday, July 20, 2017

Heads Up: Vaccine Required for College-Bound Students

As recent high-school graduates prepare to move into a college dorm, Texas physicians remind them to make sure their vaccinations are up to date, particularly one that is required for college admission. Texas law requires almost all new and transfer college students under age 22 to be vaccinated against meningococcal disease caused by the most common types of bacteria — or “serogroups” A,C,W, and Y — at least 10 days before classes begin.

“If your vaccinations are current according to medical recommendations, you likely received your first dose of the required vaccine at age 11 or 12 years because it is required for middle school entry, and then got a booster at age 16 to provide protection through college,” said Jane Siegel, MD, Corpus Christi, a pediatric infectious disease specialist and chair of the Texas Medical Association’s (TMA’s) Committee on Infectious Diseases.

Check your vaccination record to make sure you had the two shots, said Dr. Siegel, because colleges require entering students to show proof of vaccination within the previous five years.

“College students are at increased risk of meningococcal infection that can result in very serious disease, including meningitis, and that can spread among people who live in close quarters,” said Dr. Siegel, who is a member of TMA’s
Be Wise — ImmunizeSM Physician Advisory Panel. “This germ is spread through respiratory tract secretions, so living in close quarters like a dormitory increases the likelihood of spread of this organism and is the reason for this mandate to cover meningococcal types A, C, W, and Y.”

Meningitis strikes alarmingly quickly with fever, headache, severe muscle aches, and stiff neck. The symptoms can seem like flu but progress with vomiting, weakness, mental confusion, shock, and sometimes a purple rash. Emergency medical care is important because this illness can become deadly within hours.

Types of meningococcal disease include infections of the brain’s lining and spinal cord (meningitis) and/or the bloodstream (bacteremia or septicemia). Bacterial meningitis is a common term. The meningococcus bacteria spread through coughing, sneezing, sharing drinks or eating utensils, or kissing.

Additionally, a relatively new vaccine can safely prevent infection caused by a different serotype of the meningococcus organism, serotype B. This vaccine against serotype B is not required at this time because the infection is relatively rare. However, outbreaks of this infection have occurred on a few college campuses in the United States. For that reason, physicians and other health experts recommend families with 16- to 23-year-olds discuss the meningococcal group B vaccine with their physicians to decide whether to get this vaccine too.

Meanwhile, a shot to prevent cancer

Another vaccination to consider, said Dr. Siegel, is human papillomavirus (HPV) vaccine — a shot that can prevent cancers in men and women. “You may have gotten this vaccine at a younger age, but if not, start the three-dose series before heading to school, and complete the series at your college student health service,” she said. (Three doses are required if you get your first shot at age 15 years or older; only two doses are needed if you begin before age 15.)

Bottom line, she said, vaccines saves lives: “Immunizations are one of the 10 most important public health advancements of the 20th century. So, it is best to prevent what we can when safe and effective vaccines are available.”

Stay registered

Also, students who are 18 years of age should sign the consent form to keep their vaccination records in the Texas state registry. Having vaccine data in the registry allows adults to keep up with vaccinations throughout their lifetime.

“We know college students move around and participate in all kinds of special programs in the summer and throughout the year that require immunization records,” said Dr. Siegel. “Having the data available in the state registry is convenient and will allow you to get vaccine reports when you need them.”

TMA has published a fact sheet about the importance of meningococcal vaccination, in English and Spanish, as well as an infographic on HPV.

Wednesday, July 12, 2017

New Law Shapes the Future of Telemedicine in Texas

Texas physicians and telehealth providers are now playing by the same rules to treat patients by phone, computer, and other new technologies — the same as when physicians see patients face-to-face in a traditional doctor’s office visit. Senate Bill 1107, passed this session by the Texas Legislature and signed into law by Gov. Greg Abbott in late May, clarifies the framework to evaluate, diagnose, and treat patients remotely via telecommunication technology. Telemedicine can be a helpful tool for physicians to see some patients who cannot travel hundreds of miles — or even one mile — to the doctor’s office. Imagine “seeing” your physician via your computer or smartphone.

The bill-signing by the governor ends months of debate in the Texas legislature and caps more than a year’s worth of collaborative input by the Texas Medical Association (TMA), the Texas e-Health Alliance (TEHA), the Texas Academy of Family Physicians (TAFP), and numerous telemedicine stakeholders.

“I am happy and ecstatic for the patients of Texas,” said Ray Callas, MD, a TMA Board trustee and immediate past-chair of TMA’s Council on Legislation. “As technology advances, patients will have more access to physicians, resulting in fewer ER visits for minor ailments; and more patients, especially in rural areas, will have access to primary care at home via telemedicine technology.”

Sen. Charles Schwertner, MD (R-Georgetown), the author of SB 1107 and chair of the Senate Health and Human Services Committee, played a key role early in the session to bridge an impasse among competing telemedicine interests to define telemedicine and hold telemedicine services to a single standard of care. Rep. Four Price (R-Amarillo) sponsored the companion bill, House Bill 2697, and he also played a key role in crafting language to require health insurance plans to cover telemedicine as a service provided by the physicians they have under contract. If policyholders’ insurance covers this type of care, more physicians might be able to offer it to those patients. In fact, the law also requires health plans to post telemedicine payment policies — minus their contracted rates they will pay for this service — to their websites, to inform physicians.

The months of negotiation by TMA, TEHA, and TAFP to expand the use of technology in Texas medicine resulted in the core language of SB 1107, including:

  • The standard of care for a telemedicine visit is the same as a patient/ physician in-person visit;
  • The definition of a true patient-physician relationship to conduct telemedicine;
  • A physician must be able to access — and must use — clinically-relevant data in rendering a diagnosis in accordance with the standard of care; and
  • Health plans must cover telemedicine as a means of providing services to their insureds when a contracted physician performs the care.

“We are now seeing opportunities to access physicians and providers from anywhere at anytime for most any reason, thanks to technology. But technology by itself is not the solution to our healthcare challenges," said Austin-based telemedicine internist and psychiatrist Thomas Kim, MD, who testified for TMA in support of the bill, and helped craft its language. “At the end of the day, telemedicine care is medical care and should be held to the same standards and guidelines.”

The bottom line, doctors say, is telemedicine is a means of providing care to a patient; it is not a service in and of itself. It is a tool in the physician’s toolbox.

The new law is expected to expand the use of technology in health care. “Is this the end all, be all? No,” said Dr. Callas, “but it is the start of something that will allow patients to get the best care, and for physicians to be the captain of the ship to delegate and supervise the care of all Texans.”

Some of the law’s elements took effect when the governor signed it, while the insurance related provisions go into effect on Jan. 1, 2018.

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