The Journal of Integrative Health Care

The Journal of the American Osteopathic Society of Rheumatologic Diseases

American Osteopathic Society of Rheumatologic Diseases

The Journal of Integrative Health Care and AutoImmune Pathologies.

Year: 2018

Volume 1; Issue 1.
Editor for this issue: Thomas A. Naegele, DO <tanman52@swcp.com>

Table of Contents

1. Cop Docs. Are physicians changing their role as care givers and becoming policemen? Page 2.
2. Physician Long Term Diligence Scale, The Bedside Manner Scale, And Patient Types. Page 7.
3. Understanding Steroids in 2017. Page 18.
4. Understanding Software Design and Applications for the Health Care Industry. Page 31.

Prescription Monitoring. Cop Docs Take Over Health Care, 2016.

By Dr Tan

Poem by Martin Niemoller, 1946 in Germany

• When the Nazis arrested the Communists,
  I said nothing; after all, I was not a Communist.
  When they locked up the Social Democrats,
  I said nothing; after all, I was not a Social Democrat.
  When they arrested the trade unionists,
  I said nothing; after all, I was not a trade unionist.
  When they arrested me, there was no longer anyone who could protest.
• First the Nazis came…
  First they came for the communists, and I did not speak out —
  because I was not a communist;
  Then they came for the socialists, and I did not speak out —
  because I was not a socialist;
  Then they came for the trade unionists, and I did not speak out —
  because I was not a trade unionist;
  Then they came for the Jews, and I did not speak out —
  because I was not a Jew;
  Then they came for me —
  and there was no one left to speak out for me.

The PMP (Prescription Monitoring Program) is a program to collect data on undesirable people in the eyes of those that made the PMP. This is the start or an addition to the present Globalist plan for tyranny. The PMP is evil to the core. There is no reason for it, except to collect names of people.

I ran into a fellow physician the other day and asked them about the Prescription Monitoring Program.

They told me, it was great, as they can catch people lying. These patients do not tell  you the truth, they will do anything to get drugs. Just a bunch of drug abusers out there, was their reply

For myself (I answered), every time I interview a patient and ask them about their pain problems and the pain medicine they use, the patients have always told me the truth. I go on the PMP (Prescription Monitoring Program) to follow the mandate, typically taking around 10 plus minutes of extra time, only to find out what I already know. In
all the times I have use the PMP, it has never given me new information.

Not for me, my colleague replied, it is always new information and a list of doctors I know nothing about. You must be the only one, my colleague mocked me.

No, I believe I am the norm, I answered. It is you, that are one in a hundred. The difference between you and I, is that you look at your patients as criminals trying to get away with something. , I look at my patients as people with health problems. My patients do not lie to me, because I do not lie to them. I treat my patients with respect
and I am not the patients judge and jury, as you are, I am not a COP DOC, as you are.

I can understand some of your misguided thought process, as you just came out of a University Residency Training program. University Hospitals as a general rule, teach and project the “COUNTY ATTITUDE.” In the mind of most University Physicians, they themselves are the elite of the world, and patients must pass a moral turpitude test before any University Physician can ever believe them. The patients are just a bunch of criminals, trying to use the physician for secondary gain, for drugs, for what ever, that is the nature of these University “County Attitude” physicians and thus they project their own personalities on to their patients, or should I say criminals.

Yes, as a front line physician that treats patients as human beings, that treats patients for their health care issues, I look at myself as the patients’ doctor, I am not the patients judge and jury. I do not look at patients as criminals. I look at patients as people with health care problems. I am not out to “Catch the Criminal Patient,” I am out to serve the patient with my skill as a well trained and caring physician.

Now, why would anyone want to be a doctor, if they look at patients as criminals? By definition, that is the “County Attitude.” And it appears to me that you not only have it, but you drank two glasses of the kool-aide and are a proud recipient of the County Attitude and plan on wearing your badge of County Attitude-ism proudly, as so many University Physicians and Emergency Department Physicians across the entire USA.

When one starts to address the real issue, why would the Government create a PMP, and write law to force physicians to look up every patient before writing schedule drugs?

Why?

It is a psychological trick well defined in the “Communist Manifesto.” It is the trick to get everyone spying on each other and reporting it to the Government, and to believe that you are the one catching the criminals, when in reality, you are just a puppet, a puppet being used by the Government to do their evil bidding against the Citizens of our Country

When a doctor is forced to look up a patient (Criminal) on the PMP criminal patient monitoring list, the doctor sees the patient (criminal) with lists of drugs that they have gotten and all of those evil doctors that are giving patients abusive drugs. And the person (should I call them a doctor??) looking at the list, falls into the trap of believing that the patient is clearly a criminal, the patient has a list of schedule drugs around their name. And the real criminal, which is you, drank the Kool-Aide, and are following the Government mandate, to not trust anyone, to look at your very clients as criminals and to view yourself as an elite, better than anyone else. As you are the privileged one, the one that can judge the moral turpitude of the criminals (patients) you see.

You are being used. You took the hook, the line, the sinker and much more. You have abandoned GOD, and fell for the evil guise of Satan himself.

You need to get over yourself and start recognizing that you are being used. And in a very evil and malicious way.

When a patient has their name on the PMP list, with lines of many schedule drugs, the question you should be asking as a physician is “Wow, you must have a very serious problem, if you need to take this amount of pain medicine.?” “It is important to get a clear and definitive diagnosis, and to understand your health care problem as best we
can and to determine what the best therapy is for you.”

You need to take your own pulse first. Are you going to be the patient’s doctor? Or are you going to be the patient’s judge and jury? Doctors that play policemen, are the doctors that never get the diagnosis. The Cop Docs are so busy trying to find criminality in their patients, that their skills as a doctors go by the way side. Theses Cop Docs never look in the mirror, it is always the patients’ fault, it is never them. The Cop Docs like the “nice people”, “Oh isn’t Mrs McGillicuty such a nice person.”

As a physician of excellence, I am the patients’ doctor. I make no judgments, I have no preconceived notions, I do not judge people for taking scheduled medicines, I do not judge people for the color of their skin, the clothes they wear, or the way they smell, or any such thing.

Patients are human beings. I do not treat people the same, I treat people in the manner of which is appropriate for their health problem.

Are there drug abusers out there? I do not know. I have not found one yet, coming from a physician that was the medical director of an in-house drug treatment facility. I have found people with health care issues, physical issues, mental health issues, emotional issues, and life issues and they are doing what they can to live a relatively normal life. These patients are seeking a solution to their health care problems. The Cop Docs look at anyone that does not pass their moral turpitude test as criminals. And as a result, these Cop Docs have disdain for these people and quickly kick them out.

These patients then go to the street and seek out a solution as best they can. They may start taking alcohol, they may start street drugs, who knows. But when a person is not right in their health be it mind or body or both, they will seek a solution. When the Cop Docs kick them out of their elite moral turpitude practice, these patients wander doing what ever it is they have to do get right in their body and mind. These patients fall through the cracks of the system and get labeled by the elite Cop Docs as criminals. I wonder, who really is the Criminal?

Now, I wonder when the Cop Docs die and go to Heaven, do these Cop Docs have to pass a moral turpitude test given by Saint Peter?

You can bet on it.

FYI: the Prescription Monitoring Program is a Federal and State program, with Federal money. It cost over 10 million for each State. More than enough to pay for many of the people that need drug treatment programs. People do not have a diagnosis of Drug Abusers, they have real pathologic issues, be it mind and or body. Because of poor attitudes (County Attitude) by doctors, people using street drugs, alcohol and other products get labeled, it is more of a projection from the doctors personality disorder than a reflection upon the patient. The patient is seeking a solution, as doctors continue to label these people as criminals, instead of people with pathologic issues that need true health care and true therapy. The PMP (Prescription Monitoring Program) is a blatant waste of taxpayer money. It gets physicians to embrace communistic totalitarian attitudes (the County Attitude), and to look at patients as criminals, the PMP is criminal in itself. Where in the Constitution is this type of activity sanctioned??? Drug abuse

at most is a nuisance problem. The real issue are the prohibition type laws, that have created a criminal business environment in which evil, vicious, murderous behavior is standard business practices. If all drugs, pharmaceuticals, street drugs, all, were over the counter, all of those vicious, evil, murdering cartels would be instantly out of work. And as a society we could identify and treat those patients that are using schedule medications for therapy, with best practices and best outcomes.

How did we get to this place? How did the physicians fall for these communistic, totalitarian and draconian measures for which the U.S. Constitution was made to stop any such thought and/or activity. Here it has happened and the most amazing part is that around 50% of the physicians are embracing this evil.

Physician Long Term Diligence Scale, The Bedside Manner Scale, And Patient Types.

By Dr TAN
Thomas A. Naegele, DO

Brief
While doing a project called “the Medical Industry Study,” I did an additional study called the Physician Diligence Scale, in an effort to understand the different career paths and available knowledge bases that physicians had. My job in the Medical Industry Study, was to diagram the process flow of patients as they went through any health care interaction, be it at a hospital, an emergency department, an office, a nursing home, an operating room and any and all health care facilities, from when the patient entered the system, all interactions with staff, nurses, doctors, forms, billing, supplies, medicines, and to the disposition. I collected this information while working as a physician at
many different health care facilities. During this time working as a temporary physician in 8 different States and a total of three countries, there was not much to do when off work. So, after sitting around the hotel and watching TV or reading, I decided to go back to the hospitals and interview the local physicians. When meeting different physicians, patients are under the belief that there is a standard of knowledge and interaction, which of course is just not the case. What patients fail to appreciate is that people are emotional beings that think, they are not thinking beings with emotions.

Physicians are people and follow the same traits as everyone else.

I coined three terms to describe the different diligence scales for the 824 physicians that I interviewed in terms of comparing physicians daily knowledge base. The Diligence scale is the measure of how much a physician updates their daily knowledge base for their daily patient health care work.

Additionally, physicians have a bedside manner scale, which is diffferent than their diligence scale. The bedside manner scale is how well does a physician interact with patients in terms of communication skills and compassion abilities, the Bedside Manner Scale (BMS) is in part 2 of this article.

For the Diligence scale, my research discovered that there are three main values of
which associated words will work well for terms in describing this behavior:
1. Coasters.
2. Boxers.
3. Seekers.

1. Coasters measure around 50% of the present physicians within the USA today. A Coaster is a physician that studied hard in medical school, and studied hard during their post grad training, and then once they got an outside job, they just coast with their knowledge base until they retire. Coasters will take the required CME (Continuing
Medical Education) courses, but these are the courses where a vacation can also be obtained.

2. Boxers measure aroun 35% of the present physician workforce within the USA today. A Boxer is a physician that studied hard in medical school and in their post grad training, and they continue to read the typicaly 6 journals that come monthly about health care within their field/speciality. They go to their speciality college/society annual meeting, they know the group, and they pat each other on the back once a year. They keep the party line, and stay up with health care alone their party line, never swaying outside, never considering anything but the accepted in the box diagnoses and therapies that their speciality approve of.

3. Seekers measure around 15% of the present physician workforce within the USA today. A Seeker is a physician that did well in medical school, did well in their post grad training, but they are naturally curious, they cannot get enough information, they,typically read an article or more daily, they read a book about health care monthly, and,they are not only up to date within their daily work, but they are up to date on many of the specialities that they utilize. Commonly more up to date than their collegues within other specialities that they utilize. Seekers are always looking for cures. They are not interested in bandaid therapy, such as hypertension therapy, taking medicine for the rest of ones life, with no etiology on their illness, and no understanding of what the problem is and where the patient is going. The Seeker wants to know, they want to know the etiology, and then evaluate the patient for their diet, life style, and their life options. The Seekers are not parently figures that want patients to do as they say, the Seekers view themselves as consultants, as educators, for which the patient seeks out to get educated about their health care issue and in turn the patient choses for themself the therapy that they believe that they can live with. When observing through time, where the Seekers go through time, the Seekers have a tendency to enter into INTEGRATIVE Health Care, because Seekers want cures for their patients, and to date, only Integrative Health Care
has its focus on cures.

The Physician Diligence Scale Study (PDSS) was an interview study of 824 physicians over a period of 15 years. There was a formal set of questions that were asked in an informal setting. (See Question Set Below).

Out of the 824 physicians interviewed, it was discovered that 2 of these physicians were evil and malicious individuals with severe mental illness. 2/824 = 0.2 percent. If this is a true representation of US physicians, of which there are thought to be around 850,000, this would put the number of evil and malicious physicians at 1,700.

Part 2

The Bedside Manner Scale:
by Dr TAN

The Bedside Manner Scale has 5 categories. The Bedside Manner Scale is not related to the Diligence Scale. Just because a doctor is not a good communicator, does not mean that the doctor is not well informed, and just because a doctor is an excellent communicator, does not mean that the doctor IS well informed.

There are a few definitions that one needs to know to fully understand this article:

a. The One Percenters. Within health care, one percenters are a group of physicians that almost always fall into the Seeker Diligence Scale rating. These physicians get the diagnosis correct on the first visit 95% of the time, and after a given period of time, as some diagnoses, take multiple visits and multiple sets of testing, they will get the diagnosis / diagnoses correct 99% of the time and greater. One of the most difficult hurtles is when patients have multiple diagnoses. Multiple diagnoses always present with a confusing picture. As a result, it takes time, to separate the symptoms, ancillary service results and imaging results into the multiple diagnoses.

b. Physician: A physician is a professionally educated individual that interviews, examines patients and orders ancillary service testing that is guided for determining the diagnosis or diagnoses of individual patients. The Physician will interview a patient,examine the patient and come up with a differential diagnoses, which is a logical set of diagnoses that meet the interview and exam discovery. From this point, ancillary service requests are utilized to get closer to the actual and true diagnosis. Ancillary Services are laboratory, imaging, pulmonary and cardiac testing, and also they are acuptuncture testing such as the Biomeridian device, kinesiology, and many other machines and testing methods that are NOT a part of Modern Medicine but they are a part of the health care science modality. Examples include Alleopathy, Osteopathy, Chiropractic, Natureopathy, Homeopathy, Chinese Medicine, and more. Though there is antagonism between these modalities, each of these modalities has successes and failures in their own right.

c. Therapy: Therapy can be exercise, anatomical manipulation, a specific diet, a transformed diet, drugs, minerals, vitamins, procedures including surgery, and /or a combination of these items.

c. Health Care: Physicians learn Health Care, they do not go to Medical School. In fact Medical Doctor is an insult to the whole profession. Physicians are not MEDICAL DOCTORS, as the term medical doctor implies that this physician is going to use drugs for all treatments. The term Medical Doctor was promoted by the elites that owned
organic chemical plants that made drugs, in an effort to get the public to buy into the idea that drugs are the solution for any and all health care problems. In the U.S.A. there are Alleopathic Physicians called Doctors of Alleopathy, there are Doctors of Osteopathy, Doctors of Natureopathy, Homeopathic Doctors, Chiropractic Doctors, and others. Each and every one of these modalities has successes and failure. For the patient, if your health care issue is not solved by one of these modalities, my suggestion is to go to another modality. As you search, you will find a solution.

The Labels I put on the BMS (Bedside Manner Scale) are:
1. The Narcissist
2. The Avoider
3. The Which Doctor
4. The Parent
5. The Dialoger
6. The CopDoc, this is more of a subset, it can be within any of the 5.

Definitions of the 5 BMS:

1. The Narcissist.
The narcissist physician is a know it all, they know everything and if you just listen to them, all of your problems will be solved. As they say, even a non-working clock is right twice a day. In order to be a physician, one has to be a reasonably smart individual. It is difficult to get through health care school unless one can study hard, have a certain level of memorization ability and a certain level of intelligence, to be able to connect the dots with all of the information. The Narcissist truely believes they know it all. If a person brings up conflicting facts demonstrating that the Narcissist is incorrect, the Narcissist will remove that person from their life. All physicians know information about disease and illness, which is expected. However, not all physicians are One Percenters, but most physicians believe they are. Some typical quotes are after a short interview, “I have patients out there with some real problems!” in reference to the patient they are with, meaning that this patient does not have a real problem.

2. The Avoider.
The Avoider is the physician that does not want to give bad news to anyone. They are pleasers, they have this inner need to please people, and thus, when they find bad news, Avoiders avoid it, and move on to different subjects resulting in the patient not fully understanding their pathology and rarely understanding their therapy.

3. The Which Doctor.
Which doctors have the highest incidence in the emergency medicine field. They see a patient and their first question is which doctor do I send this patient to? Which doctors are not good diagnosticians, thus they always send their patient to a specialist. To someone else. If you, as a patient, go to a physician and you get sent to a specialist right away, this is a very good indicator that you are going to a Which Doctor. Today, very few specialists are one percenters. Years back, the training for specialists was so intense and voluminous, that prior to the 1980s, General Internists and most specialists were one percenters. One could count on getting the correct diagnosis if going to one of these sub fields. Today, General Internists are general practitioners that do not see children or deal with womens reproductive organ pathologies. Specialist are procedure oriented, and all they do is procedures, their skill as diagnosticians is gone. Believe it or not, the General Practitioners which do include G.P.s, F.P.s, and Some of the General Internists, are where most of the one percenters come from. The infamous WHICH DOCTORS can be found in most emergency departments, and also in those TeleMedicine Phone Line doctors. The Global Phone doctors, are famous for being Which Doctors. One calls up, and explains their health care problem and the Which Doctor on the Phone says, You need to go to the urgent care, to the ER, to this specialist. Why, because Which Doctors are poor diagnosticians and so they tell the patient to go to another doctor. And in reality, it is good advice, because Which Doctors are in the lower 10% of the diagnostician scale, and it is best to avoid their advice and interactions.

4. The Parent.

The Parent Physician treats all of their patients as children.   The patient is just plain stupid and that is all there is.   The patient should do as they are told and do not ask questions.  The patient does not need to know any details, the Parent Physician knows best and that is how it is, any questions.    I remember a physician proudly told me that a patient came in and told him that they have a health care problem, which has been diagnosed as such and such,  In the past, they have used this medicine and it has always worked.   This physician told me that everytime a patient comes in and tells them what medicine to use,  he purposely will not use it.     The logic is a cross between the Parent and the Narcissist, there is no logic, it is just plain self ego.   Here the patient knows their problem, and knows their therapy, to deny that to them, is a power play for self gain, and nothing to do with the Hippocratic oath.

5. The Dialoger.

The Dialoger is the physician that spends the time talking with their patients in a real one on one dialogue.  The Dialoger Physician will listen to the patient and they will go along with their wishes, as long as the patient listens to the physician, as the Dialoger wants to make sure that the patient understands the options, the good, the bad, and the potential outcome.    When a patient comes in and says I want an Xray, the Dialoger physician says, that is fine,  what do you expect to find, and do you know about the radiation.   The expectations for this test to discover what you are looking for is this,

and if you recognize the good and the bad,  Ok, let us get this test.     The Dialoger wants to make sure that the patient is the decision maker for their health care problems, in discovery, in therapy, in testing, and in therapy.    When the patient is in control the Dialoger Physician views themselves as a professional consultant, to educate and to guide the patient for the best outcome.   The Dialoger is not the physician that blocks the patient,  the Dialoger is the physician that informs and educates the patient.

6. The CopDoc.

The CopDoc, is the physician that looks at patients as criminals.  It is not a main theme or personality,  it is a sub-theme.   Some physicians are focused on the theme that “Patients are Criminals” until proven otherwise.   The question is are you the physicians judge and jury?  Or are you the patient’s Doctor?

Because of this now politically correct sub theme,  Doctors have allowed the Prescription monitoring Program, a program that forces physicians to COPDOC check their patients that use schedule medications.    A true physician would want all medicine, over the counter,  because that is a true physician by nature.   Patient’s need to have access to medications and they should be readily available.   Will there be problems, of course, but nothing like we have now, with Billions of tax payer money paying for the DEA, the Prisons which have more than 50% of their population with non-violent drug issues, and for the most part, the small players, for the big players are our leaders in authority.  When a person can make millions of dollars a day,  the big players get involved.

The CopDoc always suspects patients are after schedule drugs, and patients are criminals.   When a patient comes in on opiates or any schedule drug, or the patient is taking street drugs,  the true physician interaction should be  Wow, you must have a severe pain problem, let me help you figure this out and see what we can find to give you the best therapy.   The PINO, (PHYSICIAN IN NAME ONLY) COP DOC approach is, you are on opiates, you are on Street Drugs, you are drug addict, you are a criminal, get out of my office.    It is these physicians that should have their license to practice health care revoked.    This attitude is inappropriate and it does not follow the Hippocratic Oath.

I can not repeat it often enough,  Physicians are NOT the Patient’s Judge and Jury, Physicians are the Patient’s Doctor.

Part 3:

Lastly the Patient Type Scale.

Patients come in 11 types

 

1. The Child
2. The Doctor
3. The My Doctor
4. The Questioner
5. The Shopper
6. The Manipulator
7. The Conciencous
8. One More Thing
9. The Friend
10. The Professional Hall Way Patient.
11. The Pre-Paid Patient.

 

1. The Child.

The child is the patient which is always saying, “You are the Doc, what ever you say.”  They want to believe that the doctor is always right, and never wrong.      If something goes wrong, in many cases the Child will believe that it is fate,  as the doctor is always right.   However, not always.

2. The Doctor

The doctor already knows what their problem is and they want to check with a real doctor to confirm what they already know, or they want to see if there are other options.   It dealing with a narcisstic personality disorder, the patient knows it all and that is all there is to it.   It can be difficult if the patient has a serious health care problem.

3. The My Doctor.

The My Doctor, when they go to another doctor, they always bring up “My Doctor.”    And of course their doctor is never wrong,  but you are.   These patients are out of town, or for some reason have to see another doctor, and they focus a lot on what their DOCTOR would do.    When they leave, you can count on a, “I’ll call up my Doctor to see if this therapy is Ok.”

4. The Questioner.

The questioner has many questions, the quality questioner writes the questions down, and writes down the answer.   This is a good place to be,  as it demonstrates that the patient is interested and will take part in managing their health care issues.  The physician staff should never take this as a difficult patient, this is a potential Conciencous Patient,  have the Questioner write all the questions down as a first step.   Make it known that the Doctor will answer the questions that are written down, and any of the other questions, will need to be written down for the next visit, which can be in the next few days.   Some of the questions may seem inappropriate, but this is never true, the questions represent how the patient views their illness.   So, these are eye openers and ideas that need to be clearly understood by the patient.

5. The Shopper

The Shopper has an agenda.   Typically it is schedule drugs.   The Shopper is certain that they know what their health care problem is, and they know the therapy, and it is life long schedule drugs.    The take these schedule drugs and it is acceptable for them.   They feel normal while on the schedule drugs, for what ever reason, appropriate or inappropriate.   They do not want to go through any discovery, they have found the solution, and please just give me my prescriptions.  It is common that these people have personality disorders making it very difficult to have a dialogue.   The Shopper is 100% positive they understand their health care problem and the treatment is life long schedule drugs.    In order to reach these people,  the physician has to give them their schedule drugs for two to three visits, and then  say, that when taking these drugs, lab tests are required, and then proceed with the work up for their health care problem.    As patients with personality problems can be most difficult, if possible, getting a psychiatrist involved that can get the trust of this patient will get the patient into a more seeking the correct diagnosis mind set.     Shoppers’ are the patients that come once, and go to another doctor every month, and commonly do not pay their bills.    When the patient comes in and starts telling you, that you are the best doctor in the world, and they have heard about how great you are and no other doctor is any good,  this is a sign of getting ripped off.   Any time a patient tells you how great you are and how bad the other doctor is,  this is the same statement they are going to say to the next doctor they run into.

6. The Manipulator Patient.

The Manipulator is similar to the Shopper, they always tell you that you are the greatest doctor in the world, but they typically stick with you.   They know what they want, and they will get into a discussion in an effort to get you (the doctor) to make the suggestion, and then the patient is all in.   The Shopper and the Manipulator have similar personality types.    Yet the manipulator typically will stick with the doctor and even take some suggestions from the doctor, but they want to be in control whether it is correct or incorrect.    The manipulator patient is difficult to manage their health care issues, as they truely believe that the know about, and they cherry pick what the doctor says,  and thus, gets the idea incorrect.    On the next visit, the Manipulator will say, well you said I should take that medicine.   And put the blame on the doctor, when in reality, there was a long set of conditions and requirements, but the manipulator only takes the one that they like and abandon the rest.    Once recognized, the physician can make sure to put the information in the patient note so that the whole gestalt of the last visit will be clear for the next visit.

7. The Conciencious Patient.

The Conciencous patient wants to know their health care problem.   They view the physician visit as a 10 to 15 minute educational course on their health care issue.    The Conciencous patient knows that they cannot know everything, and accepts it.   However, the Conciencous patient does want to know in full detail and be the decision maker in regards to their health care issue.    In my opinion, these are where patients should be seeking to be.   As the Conciencous patients appear to have the highest quality outcomes.

8. One More Thing.

The One More Thing patient,  they typically come to the physician office with a minor complaint and then when all if determined and ready to go, the real problem is brought up as “One More Thing.”     Doc, should I be worried about coughing up blood?    This is a potentially life threatening question and no physician can ignore it.   But it would be best to bring this up first.

A physician out of Seattle told me that he has his staff prep the patient by saying,  Dr Jones has a lot of patients today and I know that you (patient) have some very concerning health issues, so lets write them down,  and we can pick out one or two that are of the highest priority and then will get back to the other problems over the next few days.

9. The Friend.

The Friend patient is a patient that wants to be friends with the doctor, even buddies.   They typically accept that the Physician is very knowledgable in their field and respects them greatly.   The Friend has a tendency to call the Physician for advice on anything health care related, since you are their friend, it surely is Ok.    These patients are actually a blessing.   You will have to step out of your way a bit more initially, however with time,  these patients truely view you as their close friend, they always pay their bill and they accept your advice.   They commonly want to call you by your first name,  this is a difficult one for me, because it is better to keep some personal distance from your patients,  otherwise you may underestimate their state of illness and / or well being.

10. The Professional Hall Way patient.

Physicians are people just like all people.   All the same personality issues, logic issues, denial issues and all.    There are physicians that recognize their health care issues and do not lie to themselves and do a very good job of managing their own care.    There are other health care professionals, of the highest esteem, that deny their health care problems until it is in a crisis state.    When a Professional (Physician, Nurse, Lab Tech) ask about their health care problems, get them to the office.   In the office, the physician is set up to do the job correctly.    For myself, I never charge any professionals.   I treat them all gratis, that is my way.

11. The Pre Paid Patient.

Some patients, such as the Pre-Paid Patient, only wants to do what is covered by their pre-paid plan.    If there is more money involved they do not want to do it.   One has to fully understand the motif of the Pre-Paid Health Plans, Insurance, or what ever the word is today,  the MOTIF is to MAKE MONEY.    None of these Pre-Paid Plans are interested in the health care of the patient that pays for the plan.   These Pre-Paid Plans set up all kinds of hurtles and road blocks in order to NOT SPEND YOUR MONEY, which is not how they see it, they see it as Their Money.

I like the plans that say,  We need a Pre-Authorization from your Doctor.    Now does a Pre-Auth Mean?  Remember the doctor does not have a contract with your Pre-Paid Plan,  YOU DO.   And according to the law,  the people involved with a contract, are the people involved in the decision making around the contract and the contract benefits.    Since the Doctor is not on the Contract, nor contract with your Pre-Paid Plan,  there is no legal authority for the Pre-Paid Plan officials to request that a doctor sign anything more or less fill out a form that is designed to make the doctor look foolish.    When one looks at these Pre-Paid Plans Pre-Authorization forms,  they are typically created by non-physicians, and these form builders ask any doctor, not a doctor that is up to date and fully informed on the subject and thus, the questions on these forms are inappropriate almost always.

My solution is that I do not take any insurance, nor do I fill out any insurance forms.   The patient has a contract with the Insurance, and thus the contract is between the patient and the Insurance Company, it is as simple as that.    I give the patient a bill, and they can submit it to the Insurance Company, some times they will reimburse, some times not.

Single Payer systems mean MONOPOLY.   And Monopoly typically mean the highest price, and because the costs get so high, the government gets involve to regulate the industry, and then it still has a very high cost.

The financial interaction between a patient and a physician, should be between a patient and a physician.   This has been studied time and time again,  this type of business arrangement always goes to free market values and the lowest costs  through time.    The Industry determines the cost of the service, and since there are hundreds of thousands of physicians, the price will get lower and lower until it is the most appropriate to pay the costs of doing business and to make a living on the side.      In the case that Third Partys, Insurance or Pre-Paid Plans want to get involved, these contracts should be between the patient and the Third Party and no one else.   Physicians should stick with charging the patient, and stick with getting the patient to pay the bill,  in the short run and in the long run, this will be the lowest cost and the highest quality of service.

Under NO Circumstances does the Physician Or the Patient want a  middleman.   If a middleman is involved the cost goes up and the service quality goes down.   Middle man and Con Man are pretty much the same term, just one has the law behind them, while the other has the law in front of them.

Understanding Steroids in 2017.

By Dr TAN   ( TANaegele, DO)

Steroids can give a quick and miraculous change in an injury or illness, thus it is easy to prescribe steroids, after seeing such miraculous results. Since the side effects are really not that common, a physician can give many prescriptions of steroids before seeing one of the serious morbidity and mortality effects from Steroids. Additionally, when a serious effect occurs,  the patient will most likely go to the emergency department and most of the time, the patient is completely unaware that their steroid course was the cause of their newly acquired infectious disease. Having clocked in over 40,000 hours in the emergency department, most of these along the Texas / Mexican border, at facilities that see 300 plus patients every 24 hours. I mention this, because this is where the problems with steroid use go, to the emergency department, because these patients commonly end up with life threaten complications.

The most important point with steroids is that there is no clear cut standard of care for the use of steroids as a first line therapy for any pathology.    There are arguable points, but if one reads the whole text, steroid use as a first line therapy is always controversial.   If one reads Facts and Comparisons, this topic is well covered.   Steroids are reserved for chronic inflammatory conditions, after multiple therapies have been proven unsuccessful.   Yes, it is a popular croup therapy, giving 1 mg /kg of dexamethasone in a single dose for croup,  also remember croup is thought to be a viral infection, and the therapy is 500 mg to 1 gram of rocephin, with 1 mg/kg of dexamethasone and racemic epinephrine nebulizer.   Though popular, it is still controversial, and it has been a recognized therapy for 20 years.   A 5 kilogram child is given 5 mg of dexamethasone, which is equivalent to 33 mg of prednisone,  how many physicians would consider giving 33 mg of prednisone to a 5 kilogram infant?     Additionally controversial is quinsy, and viral opthalmic infections.

The first time I heard of using steroids as a first line therapy for lumbosacral strain was by a mid-level, in 1997.    I have never read it in a journal article or any study.    The mid level did not understand the physiology,  and viewed steroids as strong anti-inflammatories.     Some years later, I ran into that same mid-level and  asked about using steroids for lumbosacral strain,  he said that he abandoned that therapy as a patient had died from a serious post therapy infection.    The mid-level recognized it was the steroids shutting down his immune system, but the patient and family just thought it was a different health care problem that came up.

I saw a 60 year old woman recently at work comp clinic, she was put on a medrol dose pack.   A few days after starting she developed full blown pneumonia and was hospitalized. I saw her a couple days after she was discharged from the hospital, a regular check up at the clinic.  When going over the chart, there was no doubt that the medrol shut her immune system down and her minor sinus infection moved to pneumonia, and it nearly killed her. She survived because she recognized she had a severe problem and went to the appropriate place. There are so many stories about steroids and patient morbidity and mortality, that it is hard to know where to start. I have seen so many deaths from steroids.

Some years back, a 14 year old male went to the emergency department in Ely, he was very sick. He could barely walk. Though no fever, and blood testing was negative for any abnormalities. He looked septic, that is how sick he was. His mother told me that he was in high school football and he hurt his knee and she took the lad to the doctors office, and saw the mid-level. The Mid level got a knee x ray for his painful knee, as it was believed that he had a knee sprain, and thus the mid level gave the mother a prescription for an anti inflammatory which she picked up and he started taking it.

Later it was discovered it was a medrol dose pack. A few days later he was very sick and they came to the ED. I had contacted the pediatric hospital in Salt Lake City and sent the teen there for better understanding, at that time we still did not know what medicine he had been taking. After shipping to SLC Pediatric Hospital, the emergency department called back and they said that the teen looked OK, probably from a couple liters of IV fluid, but they agreed to hold on to him over night while the mother drove over. The mother went home, packed up and drove to the SLC Pediatric Hospital. She did bring the medicine he was taking with her, but she never returned to the Ely hospital to let us know what he was taking. The teen died within 24 hours of arriving to the Pediatric Hospital. The teen had been put on a medrol dose pack. As the story unwound, it was discovered that the teen had fell on a thorn in football practice, giving a knee puncture. This gave the teen a cellulitis which was missed because the mid level did not take a look at knee, did all the joint movement testing with the pants on. A sprained knee may have done OK on a medrol dose pack, but it was not a sprained knee, it was a cellulitis from the thorn puncture.   Medrol is a very potent steroid, 5 times higher potency than hydro-cortisone.

One cannot emphasize enough, Steroids are not a first line therapy for any illness. And thus, the standard of care, printed in many, many articles, ended up with this mid level having a million dollar lawsuit, the suit was never taken to court, because expert testimony from both sides agreed that steroids are not a first line therapy. It was settled out of court for a million because the standard of care is that “Steroids are not a first line therapy for any illness. “ There may be an argument for Critical care patients, but there is no argument for outpatient care.

Utilization of steroids for any patient under 18, with out a trial of at least 3 other products would result in a successful malpractice lawsuit. In 2012, there were a mass of people that died getting epidural injections of steroids that were contaminated with a fungus. The fungal infection grew without any opposition as the steroid shut the immune system down. That is what steroids do, they shut ones immune system down.

The deaths associated with steroids is an annual labeled statistic, it is so high. The issue is serious life threatening infections. Steroids shut the immune system down, and if there is any infectious process going on, the administration of steroids is equivalent to throwing gasoline on a fire.

CONSIDERATIONS To the use of STEROIDS.

Corticosteroids shut ones immune system down. And thus, if one’s immune system is shut down, and that patient has an infection, that fire just got a dose of gasoline dumped on it.

When working along the Texas Mexican Border for 15 years, there was not a week that went by that a patient came in with a severe abscessed tooth, why? Because a practitioner gave that patient steroids for another issue, and did not bother to recognize that the patient had a smoldering infection in their mouth.
Skin ulcers; never give steroids to anyone with skin ulcers, in a few days those ulcers will double in size and the ulcer is now an ulcer with a full blown cellulitis. Acne, whoaaaaaa. Give a person steroids with acne, and their acne infection will blow up not only over their face, but their whole trunk.

Any person with dyspepsia, which is most likely Helicobactor pylori, if given steroids, they will get a stomach ulcer, you can count on it.    Any infection (and any means any), if a patient has any infectious process going on, no matter how small, if steroids are administered, that small infection will be a large life threatening infection in a few days.

Any physician, that is considering giving steroids, must examine the patient for any infection and it must be on the physical exam form. Again, Steroids are not a first line therapy. Steroids are not a second line therapy. Steroid use is way down the list.

My private practice is General Practice Rheumatology and auto-immune disease, and I end up using a lot of steroids, and through the years I have used most of them, I have a great respect for steroids. When seeing physicians prescribing steroids as a first line therapy, I can only shutter, as this is a well researched topic, to many studies to count, are available, to many to count steroid review papers are available, and most of these steroid therapy examples of patient morbidity and mortality, are from descending dose steroid therapy.

Burst (Pulse) Therapy versus Descending Therapy.

If a patient gets into a serious morbidity / mortality situation due to the prescribing of steroids as a first line therapy, it really puts the whole organization one is working for between a rock and a hard place. In order to defend the practice of prescribing steroids, one should at least be aware of Pulse / burst Steroid therapy, as it has been proven to be safer and more efficacious.

In 2002, the studies demonstrating that burst (pulse) steroid therapy gives the best outcomes in patients started hitting the journals.  I cautiously started using it. Having given descending dose steroids since I got out of residency, I like to see others using a therapy before I start it, or at least read 10 or more article in support and in opposition.  Burst Steroid therapy caught on with the critical care physicians and the rheumatologists but not many of the other physicians. Though I am not a certified Rheumatologist, I am a member and board member of the American Osteopathic College of Rheumatology.

Through the years, my private practice has moved to Rheumatologic patients and patients with autoimmune disorders that have a high interest in diet therapy.     Though I have observed some great outcomes with diet therapy, no single therapy is a solution for any given diagnosis.      As a result, I end up utilizing conventional therapies, especially steroids with the autoimmune pathologies.     And of course the mono clonal antibodies, which are basically vertical steroids,  by that I mean, the monoclonal antibodies shut down one vertical activity within immune system.    Though my main efforts are in diet control of autoimmune disorders, auto-immune disease is very difficult to keep symptom free, and though diet therapy works well, it is slow to work and no slips occur without paying for it a few days down the road.

The issues with descending dosing of steroids was the infection issues and low success rate. In the studies of burst (pulse) dosing versus descending dose therapy, the descending doses gave a satisfactory clinical outcome less than 50% of the time. Because the patient got initial heavy anti-inflammatory effect with the shutting down of  the immune system, as the dose tapered, the immune system would not return to normal.  This is the point of why physicians use descending dose steroid therapy,  as it is believed that descending dose allows the adrenal glands to start functioning again, as the dose gets smaller and smaller, it was thought that the adrenal glands would also slowly start function again.    However, with repeated studies, it was discovered that the daily descending dose was enough to prevent the adrenal glands from kicking back in to production mode of ones own steroids.     In fact, as the descending dose slowly went down the adrenal glands did not kick in until a week and sometime two weeks after the steroid dose was zero.    It was the slow tapering that delayed the adrenals back into production, just the opposite of what was thought.  Repeated observation demonstrated that the patients adrenals would not start manufacturing  for an additional 7 to 21 days once the extrinsic steroids were tapered to zero.   The inability of the adrenals to kick start, resulted in high infection rates post descending dose therapies.   This is the take home point.  It has been believed that by giving descending dose therapy, the lowering of the dose, will allow the adrenal glands to slowly start manufacturing cortisol again.    With better scientific equipment,  it has turned out that this has not been the case.   In fact, descending therapy actually prolongs adrenal shut down,  and thus Pulse Therapy is actually safer and more effective.

With pulse (also known as burst) therapy, giving 40 mg of Prednisone once a day for 7 days, on the last day, the adrenal glands started manufacturing within a day or two. The sharp cut off,  allowed the body to recognize that there was a problem and it started its correction right away. The high dose gave a very quick effect, and the patients noticed that their inflammatory symptoms were gone by day 3. And commonly the anti-inflammatory effect would last 6 weeks and even more. The result demonstrating successful outcomes in 80% of the patients. The burst therapy gives the body a straight drop, which the body immediately recognized and the body responds correctly, thus removing the super infection issue that occurs with the descending steroid dosing. The argument that descending dose allows for the adrenals to start manufacturing ones own steroids as the dose descends turned out to be incorrect. It happens to be just the opposite. The descending doses delay the adrenals restarting by 7 to 21 days, thus the high amount of infections and poor outcomes.

With the many studies demonstrating a higher safety profile and a higher quality of outcomes with burst therapy, why are physician resisting Burst Therapy and still utilizing descending therapy??? The answer is probably involved with why are physicians using Steroids as a first line therapy, when there is no standard of care protocol recognizing steroids as a first line therapy.    Or why is Rosacea still out there when the use of ivermectin was found to cure rosacea, in 2015?

How To Use Burst Therapy

Name

Days

Steroid        1 2 3 4 5 6  7

Prednisone 40 40 40 40 40

Prednisone 40 40 40 40 40 40 40

Prednisone 40 40 40 20 20 20 20

Prednisone 40 40 40 40 60 60 60

Prednisone Days  8 9 10

60 60 60

Standard Burst / Pulse Therapy is 40 mg of Prednisone once per day for 5 to 7 days. In patients that have had this therapy, as they have a chronic auto-immune disorder, they may go to 10 days. (Never more than 10 days).

This therapy can be utilized once every 3 months, for up to 10 days. If one has to use more than 10 days worth, it is not burst therapy. It is chronic steroid therapy and different rules apply.

For first time patients: If the patient feels pretty much symptom free on day 3 or 4, they continue for 5 days or 7 days, depending upon how much inflammation is involved.

More inflammation, more days.

If the patient notices that at day 2 they are nearly symptom free, to high of a dose, they cut back to 20 mg, and go with 20 mg for a total of 7 days. If a patient notices at day 4, that they still have a lot of symptoms, they add 20 mg, for a total of 60 mg and take 60 mg, once per day for ten days and stop. The next time the patient gives a trial of Pulse therapy, this patient that ends on 60 mg will start on 60 mg, and they may go up to 80 mg on this trial. I have had patients go up to 140 mg of Prednisone, but these people are out of the bell shaped curve. The patient that was on 20 mg, starts on 20 mg the next time.

In the case that the patient gets desperate, and they end up taking steroids for a long period of time,  the adrenal glands may shut down permanently.     What physicians do is stop the steroids, and give cosyntropin (ACTH)  IM, once a day, until the adrenals kick in.   This can take 30 days, with an average of 14.    In some cases the adrenal glands never start up again.   This then requires life long therapy with hydrocortisone and possibly Flortef.

Allergic Reactions to Steroids

Steroids are separated into the following 4 groups (A, B, C, and D).

If an allergy or side effect occurs within one of the products within group A, it occurs in all of the products within group A.   However, there is no cross reactivity from any of the 4 groups.      Thus, if a person gets an allergic reaction to Prednisone,  one can switch to Dexamethasone, and none of the reactions that occurred with Prednisone will occur to

Group C.

 

Group A

Hydrocortisone

Methylprednisolone

Prednisolone

Prednisone

Triamcinilone

 

Group B

Acetonides

Amcinonide

Budesonide

Desonide

Fluocinolone Acetonide

Fluocinonide

Halcinonide

Triamcinolone Acetonide

 

Group C

Betamethasone

Beclometasone

Betamethasone

Dexamethasone

Flucortolone

Halometasone

Mometasone

 

Group D Esters

Alclometasone dipropionate

Betamethasone dipropionate

Betamethasone Valerate

Clobetasol Propionate

Clobetasone Butyrate

Fluprednidene acetate

Mometasone furoate

Ciclesonide

Cortisone acetate

Hydrocortisone aceponate

Hydrocortisone acetate

hyrdrocortisone buteprate

hydrocortisone butyrate

hydrocortisone valerate

prednicarbate

Tixocortol pivalate

END OF PART ONE.

 

START OF PART TWO.

Side effects of oral and injectable corticosteroids.  Instead of just a particular area, this route of administration is the most likely to cause significant side effects. Side effects depend on the dose of medication you receive and may include:

Peptic Ulcer

Hypertension

Diabetes mellitus

Viral infections

Fungal infections

bacterial infections

TB

Osteoporosis

Epilepsy

Psychosis

CHF

Renal Failure.

Elevated pressure in the eyes (glaucoma)

Fluid retention, causing swelling in your lower legs

High blood pressure

Problems with mood, memory, behavior and other psychological effects

Weight gain, with fat deposits in your abdomen, face and the back of your neck

When taking oral corticosteroids longer term, you may experience:

• Clouding of the lens in one or both eyes (cataracts)Understanding Steroids Page 9

High blood sugar, which can trigger or worsen diabetes

Increased risk of infections

Thinning bones (osteoporosis) and fractures

Suppressed adrenal gland hormone production

Thin skin, bruising and slower wound healing

Side effects of inhaled corticosteroids

When using inhaled corticosteroids, some of the drug may deposit in your mouth and throat instead of making it to your lungs. This can cause:

• Fungal infection in the mouth (oral thrush)
• Hoarseness

If you gargle and rinse your mouth with water — don’t swallow — after each puff on your corticosteroid inhaler, you may be able to avoid mouth and throat irritation. Some researchers have speculated that inhaled corticosteroid drugs may slow growth rates in children who use them for asthma.

Side effects of topical corticosteroids

Topical corticosteroids can lead to thin skin, red skin lesions and acne.

Side effects of injected corticosteroids

Injected corticosteroids can cause temporary side effects near the site of the injection.

These may include skin thinning, loss of color in the skin, facial flushing, insomnia and high blood sugar. Doctors usually limit corticosteroid injections to three or four a year, depending on each patient’s situation.

ContraIndications

Any on going infection, NEVER GIVE Steroids.

Skin infections, never give steroids.

HISTORY OF DYSPEPSIA MAY BE H PYLORI, steroids cause ulcers.

Chronic sinus problems, will lead to infection.

STEROIDS ARE NOT A FIRST LINE THERAPY FOR ANY ILLNESS, and do not be afraid to give the patient a prescription for antibiotics, as the patient will know that they are getting a serious infection, even though there may be no clinic signs.Understanding Steroids Page 10 Steroids are reserved for specific inflammatory issues, that are associated with chronic disease. Short term steroid use has become popular because the results are quick and dramatic. However, so are the deaths and bad outcomes.

Back pain, back strain, One may consider Steroids after 8 weeks of other therapy. Prolo therapy/PRP therapy are the main stay for professional sports muscle and joint strain therapies.

Closed head injury, At 4 to 6 weeks, 5 to 7 days of burst therapy is now recommended.

However, this is at 4 to 6 weeks out, it is not a first line therapy.

Major Side Effects of steroids

If any of the following side effects occur while taking any steroid, STOP TAKING

the STEROID IMMEDIATELY.

More common:

 

Aggression

agitation

blurred vision

decrease in the amount of urine

dizziness

fast, slow, pounding, or irregular heartbeat or pulse

severe headache

irritability

mood changes

noisy, rattling breathing

numbness or tingling in the arms or legs

pounding in the ears

shortness of breath

swelling of the fingers, hands, feet, or lower legs

trouble thinking, speaking, or walking

troubled breathing at rest

weight gainUnderstanding Steroids Page 11

 

Incidence not known:

 

Abdominal or stomach cramping or burning (severe)
abdominal or stomach pain
backache
bloody, black, or tarry stools
cough or hoarseness
darkening of the skin
decrease in height
decreased vision
diarrhea
dry mouth
eye pain
eye tearing
facial hair growth in females
fainting
fever or chills
flushed, dry skin
fractures
fruit-like breath odor
full or ound face, neck, or trunk
heartburn or indigestion (severe and continuous)
increased hunger

increased thirst

increased urination

loss of appetite

loss of sexual desire or ability

lower back or side pain

menstrual irregularities

muscle pain or tenderness

muscle wasting or weaknessUnderstanding Steroids Page 12

 

nausea
pain in the back, ribs, arms, or legs
painful or difficult urination
skin rash
sweating
trouble healing
trouble sleeping
unexplained weight loss
unusual tiredness or weakness

• vision changes
• vomiting
• vomiting of material that looks like coffee grounds

Minor Side Effects

Some prednisone side effects may not need any medical attention. As your body gets used to the medicine these side effects may disappear. Your health care professional may be able to help you prevent or reduce these side effects, but do check with them if any of the following side effects continue, or if you are concerned about them:

More common:
Increased appetite

Incidence not known:
Abnormal fat deposits on the face, neck, and trunk
acne
dry scalp
lightening of normal skin color
red face
reddish purple lines on the arms, face, legs, trunk, or groin
swelling of the stomach area
thinning of the scalp hair

 

Steroid                   Length      Potency   Dosing

Dexamethasone Long-acting 25              0.75

Prednisone Intermediate-acting 4            5.0

Methylprednisol Intermediate-long acting 5       4.0

Hydrocortisone                          1.0                    20.0

Short-acting

Kenalog anti-inflammatory actions start at 24 to 48 hours after administration.

Dexamethasone anti-inflammatory actions start around 8 – 10 hours after administration.

Prednisone takes around 18 to 22 hours from administration to action.

Allergic reactions, physicians commonly jump to steroids, however, as you read below, it is most important to give the patient Epinephrine sub cutaneous or IV, and then Histamine 1 and Histamine 2 blockers as soon as possible. Steroids can be given after the above, and they may not even be needed, if the symptoms are gone.

ANAPHYLAXIS IS A SEVERE SYSTEMIC ALLERGIC reaction that is potentially fatal. It requires prompt recognition and immediate management. Anaphylaxis has a rapid onset with multiple organ–system involvement and is mostly caused by specific antigens in sensitized individuals. Reactions typically follow a uniphasic course, however, 20% will be biphasic in nature. The second phase usually occurs after an asymptomatic period of 1–8 hours, but there may be a 24-hour delay. Protracted anaphylaxis may persist beyond 24 hours. Concurrent β-blocker therapy may adversely affect the response to management. Epinephrine is the treatment of choice and should be administered immediately. Secondary measures include circulatory support, H 1 and H 2 antagonists, corticosteroids and, occasionally, bronchodilators. Post-treatment observation of these patients is necessary, and they should remain within ready access of emergency care for the following 48 hours.

One pearl to remember:

10 mg of hydrocortisone is equivalent to 4 mg of Prednisone is equivalent to 1 mg of Dexamethasone.

Understanding Software Design and Applications for the Health Care Industry

By Dr TAN

For those that are trained in software development for professionals,  there are repeated rules that assure success.     The following 7 rules are written in every software development text book across the world.    Within Health Care,  there is not one health care software packages that contains these seven rules,  in fact, one will be hard to find any of the health care software packages that have even one of the rules.    When software follows these seven rules, the result is around 3 packages, that all look very similar and operate similarly, along with cutting costs of the industry, cutting staff, producing quality unique reports for encounter, along with complete coding, billing, supply management, up to date information at the professionals finger tips and outcomes research that is true and factual.     Within health care software there are hundreds of packages, maybe over a thousand.  This tells us that we within health care that use these software packages costing us millions of dollars not only up front costs, but also in loss of production, in the requirement of more staff, and the useless information from which these available software products fabricate,  we are fools, by definition.    Print out 100 notes on 100 different patients,  you will be able to count the differences in the notes on one hand.   Get 100 hand written notes for 100 different patients,  the differences in information will be over a thousand.

If you are willing to know the truth, read on.   If you have invested millions and want to believe that you made the right choice and are willing to keep pushing more and more money into the deep hole,  you better stop right now, this article is not for you.

The Seven Rules of Professional Software Design:

Rule 1: Single Screen Design.

Single screen design is by far the most talked about and established rule for professional  software.   The reason is that highly educated professionals want a familiar face.   As with electrical engineers, that use oscilloscopes for doing their design, calculations and evaluations,  all oscilloscopes look nearly the same,  and a professional engineer can walk into a lab, and turn on the oscilloscope and be productive immediately.   All of the engineering disciplines have similar stories,  look at the professional C.A.D. programs, for each engineering discipline, there are two or three products that are in use world wide.    All have single screen designs and  all of them are so similar that going from one to another is intuitive.

The grocery industry was one of the few retail outlets that discovered a computerized methodology that was incredible, intuitive, and no change for the operators, with less work,  more efficiency and it increased the productivity 100 percent and more.

During the 1970’s many a manufacturing plant purchased some large scale computers, along with programmers from the computer company, to build software for their manufacturing company.   The failures were 100%.    Yet it was not a complete loss, these manufacturing companies, made up of engineers with engineering minds, recognized that in order for the computer to be of value, it would be necessary for in house engineers to learn how to write computer code and then design software for their company around the theme of the company products and services.    After these failures, many of these manufacturing firms sent their own engineers back to college to learn how to design and build computer programs , which was the successful ticket for getting software of excellence.    After the first costly mistake, these in house engineers designed and built computer programs that not only met the needs of their company, but these programs cut operational costs, improved productivity and collected data that would allow these companies to evaluate future needs and to meet these needs.

Gamers use multiple screens, not professionals.

Rule #2: Single and consistent input method.

Use a mouse/track ball/pen  or a keyboard, never both.   The highly skilled professional is using the computer to do their job, what ever that job is.    Making mouse moves and mouse clicks and then having to take your hands off the mouse to go to the keyboard is a costly design, in time and in effort.    No top professionally educated software designer would ever have a mouse and keyboard entry within the design,  none.   Thus, if one is using a professional software package and the user has to use the mouse and the keyboard,  it was not designed by an educated professional software designer.   You the purchaser, got duped.

When looking at the many different software products all across the Internet, one discovers  the many different designs and some of which are intuitive and easy to use, while others are difficult to understand and difficult to use,  it is from this experience that one can start to understand that there are a few top quality software designers of excellence and there  many self taught software designers that can talk a great line to bosses that know very little about software development and design,  which results in poor software designs with decreases in productivity, job efficiency and buying into them makes for costly ventures.

Designers that have both Mouse and Keyboard entry, are not professionally trained, though their hourly rate may be low,  their work demonstrates their incompetency and the users suffer greatly due to this.   Though you the purchaser got a great cost savings from the purchase price,  the cost in efficiency loss will make you look like a fool, if you have enough maturity to admit it.

 Rule #3: Professional software is always Push, never Pull.

When understanding software, software   has a basic theme of push or pull.

Push software pushes the user through the process.    The design of the software will be to push the user to the next operation.   In this way, the user does their job easily and effortlessly because within the very design of the software,  the user is pushed to the next task.  The software pushes the user along, so the user does not have to figure out what needs to be done next,  the software pushes (tells) the user what needs to be done next, and the pushing goes through out the professionals job until the job is completed.

Pull based software, is always cumbersome and by the very design it cuts efficiency and productivity by the user because the user is required to pull down the next step in order to accomplish the next step.   Pull software commonly has no real flow,  the flow is determined by the user, as the user moves the mouse around trying to determine which task needs to be done next.

Professional Software is always designed with the basic PUSH theme.   In most cases our team discovered that the purchasers have never even heard of Push versus Pull concepts,  thus, these purchases should not be in the decision making team.

Rule #4: Local, stable, and fast.

In order for a professional to achieve excellence within their work, if a professionally designed software tool is being used,  it should never run over the Internet.    A software designer that tells you that running a browser application is how the professionals do it today, is not a professional software designer, and the goal is money,  and not excellence.   Browser software is easy to keep track of, if the goal is to keep track of the software use.   However the loss in productivity is commonly 25% in standard use, and even cutting efficiency in half is unfortunately common.    A standard daily 25% cut in efficiency is a no brainer in any businessman’s mind,  yet, we see these browser products in common use and praised on how great they are and what great results they get.

These people reporting these great outcomes drank two cups of the kool-aide,  and their whole effort is a marketing ploy,  in other words, these are out right lies.   For stability, speed and maximum efficiency, the software must be run on the machine that the professional user is using.   Using a browser interpreted software package is only beneficial for the owner making money, not the professional user doing a professional job.

Does that mean that one cannot use the Internet?  Of course not.   Does that mean that each and every software installation has to be a complete stand alone operation? Of course not.   During different times of the day, the professional software can update a main server, with uploads and downloads.   The data bases and dictionaries that are used can still be on a national and/or international server.   Professional software developers fully understand these concepts, needs and requirements for professional users, and these type of uploading and downloading can occur as background processes, to keep the professionals up dated along with their colleagues around the world.

Professional software needs to be local.

Rule #5: Tagged Processing.

While a professional user is doing their job,  it is a common need to feed child processes around data that has been extracted from  the build work of the professional user.   These child processes commonly work on scripts of which are built locally (or system wide) for communications to other working staff,  billing and coding needs,  forms for outside system needs, scripts for faxes and emails, and of course prospective research needs and retrospective research needs.

With the dictionaries that are built for the professional user, labeled tags are within the design, typically the child processes have initialization tables which point to scripting instructions so that tagged items are identified and picked up by these child processes resulting in the professional users build data to enact any and all needs within this particular professional users industry for all communications,  financial aspects, supply handling, staff tasking, faxing, forms and all research aspects.    This action eliminates the need for additional time in forms processing, communication with customers, communication with staff,  capturing all financial aspects, and product research.

Tagging Dictionary data for standard work environment processes is standard within professional software design.

Rule #6: Process Flow Management.

Professional users typically, have been doing their professional job for many, many years.   The pre-computer era systems that have been developed through time have been well thought out, and it is not only essential but a staunch requirement to know and fully understand the pre-computer era systems.    This is knowledge engineering,  to take the time necessary to fully understand the existing system,  the pre-computerized system.

It is essential to understand job process flow.    How is the job actually done, and pre-computer.   What are the processes, how does the professional flow through these processes, and what were the expected outcomes in the pre-computer system.

A computer system needs to be a computer system,  not a paper system on a computer.   If you want to cut your productivity in half or even down to 25%,  computerize your paper system.    A computer is a tool,  it is not a pen and paper.    Professionals developed their system through years.    And by going through the history of the job of any particular professional, one is doing knowledge engineering.   By understanding the processes that the professional goes through to do their job,  one is getting the knowledge of the process.   And in turn, starting to understand the steps that were taken to do the  professional job, all of the steps, all of the communications all of the supplies, all of the staff interactions, all of the financial implications, from the start of the professionals job to the end disposition.

With understanding of the historical methods,  one can evaluate these methods that were done through historical time,  and instead of taking the last paper method and moving it to a computer, the knowledge engineer can understand and move the by paper method and design a true computer application.

For example,  an engineer designing a house for a customer, would have an initial interview with the customer on their needs, and wants, and maybe even show some photos of some past jobs that may have some similarities.   Today, with Computer Aided Design software,  the engineer can interview the customer and then shortly there after,  use the software to push some designs right there with the customer observing, and also get aspects that in the past may take weeks, such as zoning issues, monthly costs, building materials, the costs of utilizing different building materials,  labor needs and many, many concepts in process,

Process is a very necessary concept.   One cannot build the roof on a building, until they have the walls, and one cannot build the walls until they have a foundation, and one cannot build a foundation, until they have a design and a building permit.

All jobs are done according to process, it is the professional that appreciates the process of their particular job, the order of which the tasks must be done in order to be able to complete the building blocks that go through their particular professional task.

Professional Software is designed around Process.    And the process of health care is the physician-patient encounter,  not coding and not billing.    Duped again.

Rule #7: The Professionals job is the very hub of their industry.

This was the issue with the manufacturing software failures.   The software was built around the financial aspects.   Now this may be great for the accountants, however an industry revolves around the job that the professionals within a given industry do.

Back in the 1960s and into the early 1980s,  the excuse for software failures was “one can’t go wrong with IBM, if IBM can’t do it, then it can’t be done.”   Of course, this was not true.   It was just the fact that administrative executives would purchase an IBM computer and then hire on a team of IBM programmers to build the necessary software for their particular industry.    It took time, but some smart engineers finally convinced the executives that the present in house engineers need to take time out of their job, learn how to program computers and then build the software needed for their company.   And those that did this, were the winners.    The Professionals are the HUB of their industry.

Quality software is a system, a system designed around the processes of a particular job/business.    It is these processes of which the professionals within that particular industry, that know the hub of their system, and software development needs to revolve around the professional hub,   not the financial accounting.

HEALTH CARE COMPUTERIZATION

Now, we are ready for Health Care Software and why it is one of the biggest failures and boon boggles of our time.    This very failure within health care software has cost the health care industry (better put the patients), trillions of dollars, and if health care software continues along this path, it will cost many trillions more, along with higher patient morbidity and mortality.

The first question is,  what do you mean?  How is health care software a failure?

The computer medical note programs are all viewed as necessary evils.   In fact, if health care could just eliminate the physician,  the whole system could run a whole lot better.

Of course this logic is wrong, but it is the logic of health care administrators and the health care software winners.

On average it takes 7 minutes of physician time in front of a computer to build one page of medical note.    Handwritten notes are done at around 1 minute of time, and typically they are done in the room with the patient, during the interview and exam time.   The physician will then also write the prescriptions, and other forms during this time.

Pre-computer health care notes, the average General practice physician was seeing around 4 plus patients per hour.  6 patients per hour was not uncommon, and around 10% of the office physicians were seeing 8 patients per hour.    At 8 patients per hour, these physicians were well organized and had a well trained staff, typically 3 to 4 nurses or nurse equivalents per physician.

Today, 2 patients per hour is the norm, and 3 patients per hour, is the high speed physicians.     This is due to the computer notes.    The purchasers will now be telling themselves lies in order to make themselves not look like fools.   And yes, make sure to keep digging that hole deeper,  for year after year, million after million,  surely the software will magically transform into something use-able.  Boy, are you stupid.

If a physician office implements a computer note system, the physician can cut his nursing staff/equivalent to one rarely  two per physician, thus, a decrease on average of 2

nurse equivalents.   However, because of the computer systems, the office will need to hire an IT staff, for single offices, outside contracts that come when called, for hospital systems, a full time IT Staff.    At professional engineering shops,  the software products have such excellent error handling that shop time is never stopped.   Production keeps going.    With health care, the health care software has such poor error handling, that most health care groups have to hire on a full time staff, to manage the error handling.

If the office takes third party payment, a single physician office typically needs 3 full time people to handle the third party forms processing,  of course there is another computer system for billing and accounting.       Wait,  since the physician-patient encounter is the hub of the entire health care industry,  one would think that the billing, supply management, outcomes research, all forms processing, all communications would come off of the physician user software?   Wouldn’t that make sense?   Ah ha, you are finally getting it,  systems analysis 101 is finally getting you to connect the dots.   Not only did you get duped, you are now understanding why.

When all is said and done and accounted for, the office physician has cut their patient population in half, the office has increased staff by around 20%, and additional costs for contract IT needs, all have to be added in.   The health care software is a failure, it does not even give the office top quality patient care notes.    In most facilities, the physicians have just realized that starting from scratch on every patient is the best option, because the computer patient notes are made for the billing side of business, not for patient care.

OK, it is true,  all office physicians see this, as they are the ones paying for it,  but, but, How did you get here?

During the early days of the 1970s and 1980s, there were many small hospital financial software packages that ran on the IBM 36,  and IBM 38 platform.   The hospital computer staff, was one maybe two IT staff (someone with 6 months computer education, or on the job education in keeping an IBM System 36 or 38 up and running, and 4 to 8 data entry staff, that would type in the hospital patient name and demographics and then add in the codes to create a bill, then print them out and send them or package them up in a electronic file and send it to the third party payer.

The IBM AS 400 entered the market, a computer with a lot more beef, and it allowed for more options.

During the  1980s and into the 1990s there were a lot of small timers that had developed health care computer note products, and little by little physicians gained an interest and started to purchase these products and computer notes started.

The hospital financial packages saw that these note packages were catching on, and they became afraid that they may lose their market.    And for a very good reason,  these hospital financial packages were focused on the financial side of the health care industry, and the health care industry ran around the physician-patient encounter as the hub, not the money, the money is at best a spoke on the wheel.    The hub is the physician-patient encounter.     In fact, anyone that did the knowledge engineering saw that if a computer program could capture the physician-patient encounter data, all of information necessary to do all of the work for the entire health care industry would be available.

The Hospital financial software packages saw that they could lose this game so they built a false marketing strategy, out right lies, in order to keep the business in their field.  As these companies had capital and were established, they created a very negative  air around these physician medical note packages, and they pushed this most creative marketing strategy, which was an outright lie, but the hospital administrators did not have the intelligence to understand the concepts nor the issues and the physician users, were not the buyers.

The false strategy was the Pyramid of health care computing.    The professional software engineers thought it was hilarious.    Surely no one would fall for this deceptive tale of disinformation,  yet to the astonishment of the professionals,  the health care administrators not only fell for it, they embraced and and defended it.   WOW!,

Physician Notes

Nursing Notes

Order Entry

Department Communications

The base financial software the building block Base

WOW, with all of the knowledge the professional software developers had learned through the 1960s and 1970s,  with the  failures of so many manufacturing industries following the the line “if you fail with IBM, then it could not be done anyway”, only to find out that when these same failed software projects by the “Big Boys”  was over come by the companies sending their own engineers back to school to learn the art of computer programming,  and with the massive successes and the great productivity and solutions,  yet, as those that have worked in the health care industry have found out, the health care industry never learns from the failures and successes of other industries, and for the most part, the health care industry does not even learn from its own failures, as years go by, and massive amounts of money gets spent, and the failures perpetuate, and still no one has the maturity to say,  HEY,  Computerization of Health Care has cut the production in half and more, increased the cost by double, and increased the number of necessary staff and has decreased the quality increasing industry morbidity and mortality,   HEY, Don’t you think we should recognize this?????”

And one more important point,  hospital administrators that know very little about professional software, and they know very little about the job as a physician or a nurse, have been the purchasers.     Hospital IT personnel have been on the purchasing committees,  for the hospital administrators and the physicians, all whom know very little about professional software development,  somehow got this idea that the IT Staff are experts in software analysis.     Hospital IT staff, please do not be offended at this factual and truthful information,  hospital IT staff are not college trained professional software engineers.    The typical education of a hospital IT staff is 3 to  6 months of education in learning how to use networking software and how to hook up a network and install software.      They have no training in systems analysis, no training in data base management , data base design,  data base development,  dictionary structure, design and software interfacing,  single screen designs for professional users, and last but not least, hospital IT staff have no training in being a nurse or a physician.

Let us sit down and go over what the Professional Software developers have known for years.

Rule 1: Single Screen Design.

How many computer medical note programs have single screen designs??

Well that is easy.  NONE.

Rule #2: Single and consistent input method.

How many computer medical note programs use a single and consistent input method,  that is Mouse along,  Pen alone,  Keyboard alone????

This one is an easy one too.   NONE.

Rule #3: Professional software is always Push, never pull.

How many computer medical note programs follow the PUSH theme, pushing the professional user through the process?

Again, another easy question,   NONE.

Rule #4: Local, stable, and fast.

How many computer medical note programs run locally and not across a web browser?

There are some, yet out of the 11 products I have used, the answer would be NONE.

How many computer medical note programs are stable, never fail, have excellent error handling, that you can count on?   Out of the 11, I have used,  NONE.

How many computer medical note programs are as fast as hand written notes?

This is also an easy one,  NONE.

You need to get this in your mind,  the software must run locally, the data for patients must be locally, if an internet error occurs, the physician user can still work and see patients and be productive.    Transfers to a big server can be done at night, after the staff is gone.   Computers are smart, and can do work in batch mode.   Not all processing needs to be done in demand mode.

Rule #5: Tagged Processing.

How many computer medical note programs allow the user to tag processes on to their data, such as prescriptions,  surgical request forms,  doctors excuse forms,  nursing orders, consult letters, and on and on and on,    Again, not an additional pull down task, but just the physician building the note and the note has tagged dictionaries that will automatically generate child processes and actions?

Another easy one,  NONE.

Rule #6: Process Flow

How many computer health care note programs allow the physician to build their health care note, collect their data, following the process in which the physician actually does their job?

Another easy one,   NONE.

Rule #7: The Professionals job is the very hub of their industry.

How many computer health care physician user note programs run the entire system?   Completely scalable, from one physician, to 10,000 physicians, seamless interface,  and from the physician note, be able to determine all actions, all forms, all billable, all faxes, all communications, all research, all supply inventory, all auditing, and all of the health care processes that need to be done, because the Physician Patient Encounter is the HUB of the entire health care industry and from the physician note, all actions, all communications, all supplies, all inventories, all communications, all financial, all everything is determined.     And, how many computer health care notes do this?

NONE.

CONCLUSION

With all of the development in professional software engineering and design,  the health care industry apparently has not looked at any of it.    The decision makers for health care software have been people that do not know the professional job of the physician, nor do they understand the basic concepts of system design which repeatedly emphasizes full understanding and appreciation of the existing professional system.     The health care software developers have viewed the physician note as a necessary evil,  not the hub of the entire health care system;    The present software developers for health care, did not follow any of the 7 major points of professional software development,  which tells us in plain black and white, that the health care software developers are NOT professionally trained software engineers.

There are hundreds if not well over a thousand health care software packages.  If looking at Word Processing,  there are three OPEN OFFICE type software packages.   If looking at the engineering fields for each sub specialty within engineering there are around 3 professional C.A.D. programs in use.     This is a very important observation, why?  Because when a solution is there, there will only be a few products.   If you look at the C.A.D. products and the Office Word Processing products, you will notice that they all follow the 7 rules, which are stated above and in every software development text book across the world.

When there are 10 or more software packages for any given industry, the solution has not been found.    There are hundreds of health care software packages,  the solution has not been found,  and the reasons are obvious.    We Folks In Health Care are not paying attention.

The solution:

If you the purchaser are involved with a large group of physicians,  you may be able to find a physician with a history of computer programming/ systems analysis,  preferrably someone from the 1970s to the 1980s.    This era allowed for the college trained software coders to understand batch versus demand mode, and to recognize that professional software needs to increase productivity, cut staff, and increase quality.   Build your own team.   Health care is not rocket science within the world of software development.

A team of:

1. One to two physicians that has formal college training in computer programming and coding experience from 1970 to 1986, as the designer and software testing agent. A physician that knows of the 7 rules of professional software development,  designing for add on technology, such as TI’s DLP technology,  the star trek tri-corder is where health care needs to head, fax, email, data base design, etc.
2. One software engineer with at least 15 years within systems programming, knows how to write drivers, operating systems, data base interaction, and primitives for graphics and new technology, and has the ability to be a team leader.
3. Three software engineers with a few years of experience, that can be assigned tasks by the lead engineer, and can get help from the lead engineer when needed.
4. One general manager, knowledgeable in doing larger scale projects, familiar with Gant charting, or any of the Program/Project Charting methods for defining step wise goals and achievements. Along with writing reports on the progress, and technical manuals.

Then, it will take around 12 months to get a use-able product,  and an additional 12 months to develop all of the error handling.

Assign one clinic as the first site.  Keep the project quiet.   Do not write articles on it, nor let any others know about it.   Why?   When there is a trillion dollar industry, do you think that someone or some company that is building a product that will create a paradigm shift will not get beaten on or even permanently removed?      Until the product is completed and in full operation at, at least 5 clinics,  keep a lid on it.    A product that will remove the coding and billing industry will not be a hit with over a million people that are now depending upon the physician coding and billing industry for full and part time work.    A product that allows a physician to build a patient note at under a minute per page, and the note reads as good and as unique as dictation and hand written, with completely structured data,  is worth killing for.    There are hundreds if not a thousand computer patient note products, and the product that is built that will eliminate all of those products,  will create a very angry group of people.     A product that describes a true physician-patient encounter in every detail, will solve health care pathologies through time, because the research will be dependable and reliable, and on millions of patients.