Helping Patient Decide in an Evidence-Based World – Part 3

In a previous post, we discussed the need for providers to stay up-to-date on the latest evidence-based medicine so that they can help patients make the best decisions for the healthcare. At the same time, we acknowledged the fact that the sheer volume of material available makes it difficult for providers to keep up-to-date on the latest research. These research tools and databases can assist providers by producing current summaries of the evidence about a wide variety of clinical topics.

TRIP Database –
The TRIP Database is described as a “clinical search engine designed to allow users to quicly and easily find and use high-quality research evidence to support their practice and/or care.” Access to the site is through a free registration. Searches on the database bring up links to the source articles on any particular topic. While TRIP is not focused on integrative healthcare (IH), many topics relevant to an IH practice do include citations of mainstream medical literature that report on such care.

Natural Medicines –
Natural Medicines (formerly Natural Standard) is self-described as the “The most authoritative resource available on dietary supplements, natural medicines, and complementary alternative and integrative therapies.”

For each therapy covered by Natural Medicines, a research team systematically gathers scientific data and expert opinions. Validated rating scales are used to evaluate the quality of available evidence. Easy to understand grading scale and cross-indexing by condition is available to save your time. All data is incorporated into comprehensive monographs which are designed to facilitate clinical decision making. All monographs undergo blinded editorial and peer review prior to inclusion in Natural Medicines databases. In addition to now-familiar symptom checkers and calculators, the NM database offers comparative effectiveness tables, drug/natural medicine interactions and drug and natural medicine depletion guides.

Natural Medicines is “impartial; not supported by any interest group, professional organization or product manufacturer.”

Natural Medicines is a fee-based product. They also offer a free monthly newsletter “covering news and events on herbs, supplements, exercise, nutrition, complementary and alternative medicine modalities, practices, and policy.”

Concussion-Related Migraines in Young Adults

Are you asking your young adult patients about their participation in sports – particularly sports that carry a high risk of concussion? A recent survey presented by the American Headache Society (AHS) at their 57th Annual Scientific Meeting indicates that concussion-related migraines in young athletes are more common than previously thought. If you treat young adults for headaches or migraines it may be useful to inquire about their athletic pursuits as part of your intake questionnaire.

To read the Medscape review of the presentation, please click here.

Helping Patients Decide in an Evidence-Based World – Part 2

In a previous post, we discussed the need for providers to stay up-to-date on the latest evidence-based medicine so that they can help patients make the best decisions for the healthcare. At the same time, we acknowledged the fact that the sheer volume of material available makes it difficult for providers to keep up-to-date on the latest research. These research tools and databases can assist providers by producing current summaries of the evidence about a wide variety of clinical topics.

DynaMed Plus –
According to their website, “DynaMed Plus™ is the clinical reference tool that clinicians go to for answers. Content is written by a world-class team of physicians who synthesize the evidence and provide objective analysis.” Independent studies have ranked DynaMed Plus higher that other clinical reference services in its category.

Ron Lebfvre, DC, of UWS notes, “DynaMed is an example of what some people call pre-digested literature – someone not only reads the primary research but pieces it together almost like a continuously updated textbook. Think of Dynamed as a destination site rather than a search engine looking for research articles.”

Washington-licensed providers may access DynaMed through Heal-WA. Many DynaMed topics include integrative healthcare treatment options. All statements are accompanied by a grading of the supporting evidence. It is interesting to compare the levels of evidence that support integrative healthcare interventions versus conventional medical treatments. Each entry also provides a reference list.

Cochrane Collaboration –

The Cochrane Collaboration is an independent network of researchers, professional, patients, carers and people interested in health that spans the globe. They have over 37,000 contributors that hail from more than 130 countries – all working together to produce health information that is credible, accessible, and free from commercial sponsorship or other conflicts of interest.

Cochrane is useful for anyone who is interested in high-quality health information that can be used to make health decisions – both patients and providers. The site includes editorials, reviews, special collections and evidence summaries. Many of the resources on Cochrane are free to the public and appropriate for patient consumption. The Cochrane Database of Systematic Reviews has free access for many people in low- and middle-income countries and general access licenses available for professionals.

Concussion Recovery Not as Fast as Estimated

A recent study in the British Journal of Sports Medicine indicates that recovery from a concussion might be far longer than previously estimated – by up to 400%! In the study conducted by Anthony Kontos, PhD, researchers noted that athletes took three to four weeks to recover – based on testing and self-reporting for four weeks past the diagnosis of concussion.

To read the Medscape article and the research, click here. (You will need a free Medscape account in order to view this link.)

Helping Patients Decide in an Evidence-Based World – Part 1

The role of providers in clinical decision-making has evolved from “the doctor always knows best” to a more collaborative and shared decision-making process. While some have argued that patients often favor being told what to do by a medical expert, the ethical principle of autonomy acknowledges that patients do indeed have a right for having “nothing about me without me.”

In the world of integrative healthcare, it has long been recognized that patients tend to be more self-actualizing and thus, much more engaged in collaborative healthcare decision-making. Integrative healthcare clinicians typically create therapeutic relationships based on collaboration and “meeting patients where they are…”

Evidence based medicine (EBM) consists of three elements. First and foremost are the patient’s preferences and expectations. Second is the clinician’s skill, experience, and expertise applied to the clinical problem. And the final element is using the best available evidence to make an informed decision. This last element can be a formidable obstacle in that the “evidence” is contained in published scientific and clinical research journals that accumulate at a prodigious rate. An individual in a busy practice obviously cannot keep up with the volume of new research that is published every year.

Fortunately there is a growing presence of clinical knowledge databases that can assist integrative healthcare clinicians in assessing the current state of scientific understanding regarding a variety of clinical questions, diagnostic criteria, and therapeutic options. While most of these are conventional medicine-oriented, some of them do a reasonable job of including integrative healthcare options. These sources use technology to perform continuous literature searches and produce up-to-the-minute summaries of the evidence about a wide variety of clinical topics.

Over the next few weeks we’ll be posting information about a variety of clinical reference tools that can be used by integrative healthcare providers. While most are clinician-focused, some also have content that is developed for a patient audience. In either case these tools can provide information for clinicians to help their patients make clinical decisions. By marrying the patient preferences with the provider’s clinical expertise to interpret the clinical literature together they can make decisions based on the best evidence. This is the practice of patient-centered, evidence based health care.

Can chiropractors really solve the painkiller crisis?

The American Chiropractic Association (ACA) has created an initiative to help curb opioid overdose, misuse, and abuse in the U.S. during National Chiropractic Health Month (NCHM), which is annually in October. There has been increasing volumes of information highlighting the severity of the opioid problem in the United States. A new article on Forbes Magazine website reviews the ACA’s #PainFreeNation initiative which suggests that non-invasive, non-pharmaceutical treatment options should be exhausted before trying medication-based strategies. Some of the alternatives for pain management suggested include acupuncture, yoga, chiropractic, psychotherapy, and physical therapy. Read more at Forbes Health.

More ICD-10 events added in September!

CHP is pleased to announce that we’ve added three more mini-workshops for ICD-10 preparedness to the schedule for September 2015! Check out the registration site here. (Please note that the 9:00 am class on September 3 is already full.) Each class has a maximum capacity of 16 people, so we expect these to fill up quickly. Register today to reserve your seat!

Best Practices: Documenting the Diagnosis in Clinical Record Keeping

The clinical record must contain documentation of the physician’s assessment of the patient’s condition that is being treated.

Documenting the Diagnosis
The diagnosis itself must be consistent with and supported by the patient’s presentation and the examination and laboratory findings. Initially the diagnosis is often only the diagnostic impression or working diagnosis. On follow-up visits the diagnosis should be confirmed as the clinical thought process continues.

Documentation of return follow up visits (usually in the “A” portion of the SOAP note) must include a statement of the diagnosis that reflects changes in the patient’s condition as a response to time, treatment, and other interim events (e.g., “Cervical strain, resolving” or “fatigue, improving”). The “A” should be updated as necessary to be an accurate portrayal of the patient’s present condition.

Diagnosis codes used on a health insurance claim form must be supported by the information in the patient clinical record.

The International Classification of Diseases (ICD) is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics. The ICD-9 was published by the World Health Organization in 1977. The National Center for Health Statistics created an extension of ICD-9 so the system could be used to capture more morbidity data. This extension was called “ICD-9-CM”, with the CM standing for “Clinical Modification”. The International Classification of Diseases, Clinical Modification (ICD-9-CM) is based on the ICD-9 but is used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S. Every health condition can be assigned to a unique category and given a code from ICD-9-CM.

Transition to ICD-10-CM will occur October 1, 2015. Most, but not necessarily all, payers will stop accepting ICD-9 codes and start accepting ICD-10 codes. The diagnosis codes in ICD-10 are more specific and more detailed. For example, left and right side conditions (e.g. extremity conditions) are now two different diagnoses. And there are different diagnoses for certain conditions seen at an initial encounter, in follow up “subsequent” encounters and as a sequela. As with ICD-9 codes, the clinical record must support the code used to document the condition or as used on an insurance claim form.

Note: Some integrative healthcare providers are prohibited by law from making a differential diagnosis. Therefore, this “best practice” recommendation may not apply to acupuncture or massage therapy. However, many diagnosis codes in both ICD-9 and ICD-10 are symptoms only and do not imply that the provider has made a “differential diagnosis.” For example, “neck pain/cervicalgia” is 723.1 (ICD-9) and M54.2 (ICD-10)

Washington Post reports “text neck” becoming an epidemic

“Text neck” is a danger to anyone who uses a smart phone. Do you ask your patients how many hours per day they spend with their head down staring at their phone? The majority of us do it to some degree, and as the angle that your neck bends forward and down increases, so does the weight or force through your cervical spine. This article in the Washington Post reports on a recent study about “text neck” and provides specific information about the effect of the texting position as well as some solutions to help reduce the strain.

Best Practices: PARQ in Clinical Record Keeping

Informed consent is a process involving verbal discussion as well as proper documentation. CHP recommends as a “best practice” that informed consent be fully documented and included in the clinical file.

One common option for documenting informed consent is noting the acronym “PARQ” which can be written in the patient’s chart indicating that the provider has explained the procedures (P), viable alternatives (A), material risks (R), if any, and has asked if the patient has any questions (Q). “PARQ” should be noted prior to the implementation of any treatment. If the patient requests further information or has specific questions, the provider can underline the PARQ chart notation to reflect the patient’s request. The provider should note the particular question and note the more detailed information provided. While this is an appropriate method of documenting that this process has occurred, there is no substitute for the patient’s written confirmation of those facts.

It is also recommended that the patient execute some document acknowledging that they have been part of an informed consent process, the material risks have been disclosed including a description of those risks and that the patient has agreed (“consented”) to the procedures understanding any risks inherent to that procedure. This could be accomplished using a prepared written consent form that must be signed by the patient and should be signed by the doctor. Again, it is important to note that practitioners should not rely exclusively on those forms and must communicate directly with the patients.

As new conditions occur that may require different evaluation procedures or different treatment procedures, additional informed consent should be obtained from the patient. In addition, consent given to one physician is not consent for any other physician unless the patient agrees to the substitute. This assent to the substitute physician should be noted in the clinical record.

The Minor Patient (In the US, minor is legally defined as a person under the age of 18)
As with all patients, informed consent is required for minor patients. There are different considerations required based on the type of provider delivering the service, e.g. DC, MD, as well as the services that are being provided, e.g. chiropractic adjustments, reproductive healthcare. For the purposes of Best Practices, it is recommended that the provider review the specific statutes or rules regarding obtaining informed consent from a parent/legal guardian or the minor patient, whichever is appropriate, that applies to the services rendered in the state in which they practice.

Want more information on record keeping or other best practices for integrative healthcare providers? Search “best practices” on this site to read more in this series of articles.