Sachin H. Jain

Practicing Medicine in the Age of Facebook

Social-networking sites facilitate communication, but also create new challenges for those who work in clinical settings. Dr. Sachin Jain describes receiving a “friend request” from a former patient on Facebook. Despite certain reservations, he clicked “confirm.”

Achieving Meaningful Use of Health Information Technology: A Guide for Physicians to the EHR Incentive Programs

Over 30,000 clinicians have already qualified to receive initial incentive payments for the meaningful use of electronic health records (EHRs) through the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Programs. However, 2012 is the final year to receive maximum incentive payments, and many physicians still have questions regarding meaningful use objectives and how to register for, report, and attest to meaningful use. We provide herein an overview of the Medicare and Medicaid EHR Incentive Programs and guide physicians in the process of how to demonstrate meaningful use of health information technology.

The digital phenotype

In the coming years, patient phenotypes captured to enhance health and wellness will extend to human interactions with digital technology.

Assessing Individual Physician Performance: Does Measurement Suppress Motivation?

DURING THE PAST DECADE, THE MEASUREMENT OF physician performance and offering incentives as a means of improving care have been the focus of many governmental, private, and professional groups. Performance measurement systems typically use discrete, validated clinical measures. Even though the results of these approaches have thus far been equivocal, performance measurement is already being firmly established in health care. The Affordable Care Act contains requirements for the Centers for Medicare & Medicaid Services to use consensus measures for payment rewards in programs such as the Physician Quality Reporting System (PQRS) and the meaningful use regulation in electronic health record use. Although hospital-based quality reporting and pay-for-performance have yielded some impressive results, it is uncertain whether the same will hold true in the performance of individual physicians. Underlying questions about individual performance include uncertainties about how to assess the influence of individual physicians in teams and systems of care and the role financial incentives should have in motivating physicians. If US society needs physicians as change leaders, it must consider how their motivation is affected by assessments that quantify and reward their behaviors. The motivation of highly skilled persons who perform complex work has been widely studied in the management sciences and psychology literatures. Insights from these disciplines should be considered as incentive programs in health care are developed and refined. Trisolini described a complex interaction of both extrinsic and intrinsic sources of motivation that contribute to physician behavior. In addition to financial rewards and lifestyle considerations, recognition and patient appreciation play important roles in motivating physicians. These factors interact with intrinsic motivators such as feelings of accomplishment associated with completing difficult tasks; satisfaction delivering positive clinical outcomes; and experiencing autonomy, respect, and collegial relationships. Pink has distinguished routine task-oriented work, in which financial rewards for specific results are effective in achieving those results, from more complex problem solving. Focusing on specific outcomes does not reward skills or result in managing complexity, solving problems, or creativity. Indeed, Pink suggests such reward systems will undermine these desirable attributes. Translating the ideas of Trisolini and Pink into a clinical medicine context leads to several recommendations: pay physicians a rewarding yet reasonable salary rather than piecework rewards, provide a direct ability to influence patient outcomes, and offer a continual sense of accomplishment and recognition. These would represent a more effective approach to motivating performance than specifically paying for production functions. Measuring performance is important, particularly when the metrics developed are shared with clinical teams and identify shortcomings that can be acted on to produce needed improvement. Group practices that share performance data among clinicians and managers find that merely making performance data transparent stimulates improvement— absent any additional financial incentive. This observation suggests that a number of the motivations such as mastery, accomplishment, and professional pride are acting in the clinical setting. Another important factor in the ability of performance measures to influence quality improvement involves the direct relationship of the measure to the actual role of the physician and the ability of the physician to act effectively on the specific measure. Many current pay-for-performance programs do not provide useful information that an individual physician working within a clinical team can directly influence. Health plan data often reflect a small portion of the physician’s patients, and attribution can be suspect. With Medicare’s PQRS, the performance reports of a few isolated measures, only for Medicare patients, contain data that can be as much as a year old and are not useful for improvement cycle and feedback interventions. Clearly, more timely all-payer reports would make these data relevant to the practice and useful for improvement. Hospital management and payers must partner collaboratively and transparently with physicians to help them

Characterizing Sleep Issues Using Twitter

Background Sleep issues such as insomnia affect over 50 million Americans and can lead to serious health problems, including depression and obesity, and can increase risk of injury. Social media platforms such as Twitter offer exciting potential for their use in studying and identifying both diseases and social phenomenon. Objective Our aim was to determine whether social media can be used as a method to conduct research focusing on sleep issues. Methods Twitter posts were collected and curated to determine whether a user exhibited signs of sleep issues based on the presence of several keywords in tweets such as insomnia, “can’t sleep”, Ambien, and others. Users whose tweets contain any of the keywords were designated as having self-identified sleep issues (sleep group). Users who did not have self-identified sleep issues (non-sleep group) were selected from tweets that did not contain pre-defined words or phrases used as a proxy for sleep issues. Results User data such as number of tweets, friends, followers, and location were collected, as well as the time and date of tweets. Additionally, the sentiment of each tweet and average sentiment of each user were determined to investigate differences between non-sleep and sleep groups. It was found that sleep group users were significantly less active on Twitter (P=.04), had fewer friends (P<.001), and fewer followers (P<.001) compared to others, after adjusting for the length of time each users account has been active. Sleep group users were more active during typical sleeping hours than others, which may suggest they were having difficulty sleeping. Sleep group users also had significantly lower sentiment in their tweets (P<.001), indicating a possible relationship between sleep and pyschosocial issues. Conclusions We have demonstrated a novel method for studying sleep issues that allows for fast, cost-effective, and customizable data to be gathered.

Societal Perceptions of Physicians: Knights, Knaves, or Pawns?

THE BRITISH ECONOMIST JULIAN LE GRAND SUGgested that public policy is grounded in a conception of humans as “knights,” “knaves,” or “pawns.” Human beings are motivated by virtue (knights) or rigid self-interest (knaves) or are passive victims of their circumstances (pawns). A society’s view of human motivation influences whether it builds public policies that are permissive, punitive, or prescriptive. Le Grand’s observations were drawn from his studies of British social welfare policy and civil servants but could aptly be applied to physicians and their role in the US health care system. Many health care debates—especially those relating to health care financing, quality, and education— implicitly prescribe a view of physicians and their underlying motivations. Depending on the perspective, physicians are either in practice for the betterment of society or their own selfish gain; or they are automatons whose actions are defined more by external rules and regulations. In this Commentary, we explore the ways in which physicians are variously represented as knights, knaves, and pawns in public discourse and relate the importance of designing policies that match the true motivations of physicians—whatever they may be.

Beacon communities aim to use health information technology to transform the delivery of care.

The Beacon Community Program, authorized under the 2009 American Recovery and Reinvestment Act (ARRA), aims to demonstrate the potential for health information technology to enable local improvements in health care quality, cost efficiency, and population health. If successful, these communitywide efforts will yield important lessons that will assist other communities seeking to harness technology to achieve and sustain health care improvements. This paper highlights key programmatic details that reflect the meaningful use of technology in the fifteen Beacon communities. It describes the innovations they propose and provides insight into current and future challenges.

Medicine's uncomfortable relationship with math: calculating positive predictive value.

In 1978, Casscells et al1 published a small but important study showing that the majority of physicians, house officers, and students overestimated the positive predictive value (PPV) of a laboratory test result using prevalence and false positive rate. Today, interpretation of diagnostic tests is even more critical with the increasing use of medical technology in health care. Accordingly, we replicated the study by Casscells et al1 by asking a convenience sample of physicians, house officers, and students the same question: “If a test to detect a disease whose prevalence is 1/1000 has a false positive rate of 5%, what is the chance that a person found to have a positive result actually has the disease, assuming you know nothing about the person’s symptoms or signs?”

An Early Status Report On The Beacon Communities’ Plans For Transformation Via Health Information Technology

The Beacon Community Program is part of a federal strategy for using health information technology as a foundation to improve the nations health care system. In particular, Beacon Communities seek to increase the quality and efficiency of health care, improve the health of individuals and communities, and inform similar initiatives in other parts of the country. Each Beacon Community has set quality, efficiency, and health-related goals, and each is deploying multiple technology-enabled interventions to achieve them. Yet achieving large-scale and sustainable health care improvement also requires an implementation framework that can foster innovation and continuous learning from results. Based on the early experiences of the seventeen diverse Beacon Communities, this paper describes program design features that characterize how these initiatives are organized.

The Racist Patient

As I reflected on what happened that night, I realized that no one had ever raised the possibility that I might one day be hurt by a patients words or actions.