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Update February 2019

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Health & Wellbeing

Telemedicine's challenge: Getting patients to click the app

Caitlin Powers sits in the living room of her Brooklyn apartment in New York, and has a telemedicine video conference with physician, Dr. Deborah Mulligan. (AP Photo/Mark Lennihan)

 Tom Murphy

Walmart workers can now see a doctor for only $4. The catch? It has to be a virtual visit.

The retail giant recently rolled back the $40 price on telemedicine, becoming the latest big company to nudge employees toward a high-tech way to get diagnosed and treated remotely.

But patients have been slow to embrace virtual care. Eighty percent of mid-size and large U.S. companies offered telemedicine services to their workers last year, up from 18 percent in 2014, according to the consultant Mercer. Only 8 percent of eligible employees used telemedicine at least once in 2017, most recent figures show.

"There's an awful lot of effort right now focused on educating the consumer that there's a better way," said Jason Gorevic, CEO of telemedicine provider Teladoc Health.

Widespread smartphone use, looser regulations and employer enthusiasm are helping to expand access to telemedicine, where patients interact with doctors and nurses from afar, often through a secure video connection. Supporters say virtual visits make it easier for patients to see a therapist or quickly find help for ailments that aren't emergencies. But many still fall back to going to the doctor's office when they're sick.

Health care experts have long said that changing behavior can be hard. In telemedicine's case, patients might learn about it from their employer and then forget about it by the time they need care a few months later. Plus emotions can complicate health care decisions, said Mercer's Beth Umland.

"My little kid is sick, I want them to have the best of care right away, and for some people that might not register as a telemedicine call," she said.

Some patients, especially older ones, also just prefer an in-person visit.

"Going to the doctor's office is a big event in their life and something they look forward to," said Geoffrey Boyce, CEO of InSight Telepsychiatry, which provides virtual mental health services.

Tom Hill is among that crowd. The 66-year-old from Mooresville, Indiana, said he's never used telemedicine and has no plans to.

"I believe in a handshake and looking a guy in the eye," said Hill during a recent shopping break at a downtown Indianapolis mall. "I don't buy anything online either."

But the practice does gain fans once patients try it.

Julie Guerrero-Goetsch has opened her MDLive telemedicine app several times since first using it about a year ago to get help for a sinus infection.

The Fallon, Nevada, resident was skeptical, but she didn't have time to go in person. MDLive connected her to a doctor soon after she opened the app. She said he started asking questions about symptoms "just as if I was sitting in a doctor's office" and prescribed an antibiotic.

Caitlin Powers tried telemedicine recently after hearing about it through a friend. The Columbia University graduate student was feeling stuffed up and worried she might be coming down with the flu. She said her appointment started on time, lasted 10 minutes, and she spoke by video with a doctor in Florida while never leaving her Brooklyn apartment.

"As a student, I don't really have time to spend three hours waiting to see a doctor, and this was so easy," she said.

Doctors have used telemedicine for years to monitor patients or reach those in remote locations. Now more employers are encouraging people covered under their health plans to seek care virtually for several reasons.

Telemedicine can reduce time spent away from the job, and it also can cost half the price of a doctor's visit, which might top $100 for someone with a high-deductible plan. However, those savings can be negated if telemedicine's convenience causes people to overuse it.

Walmart said it cut the cost for virtual visits to give another care option to the more than one million people covered by its health benefits.

Employers aren't the only ones pushing the technology.

The drugstore chains CVS Health and Walgreens are promoting apps that let customers connect to doctors. Some insurers like Oscar Health are offering it for free to customers as a first line of treatment.

Ease of use is one of the reasons researchers and telemedicine providers think the practice will become more widespread in several areas of care. Those include dermatology and follow-up doctor visits after a surgery or medical procedure.

Mental health visits are another area ripe for virtual care because patients can feel more comfortable talking to a therapist in their own home, said Boyce of InSight Telepsychiatry, which delivers mental health care in about 30 states.

Boyce said people also like the anonymity of a virtual visit.

Mental health visits were the most common use of telemedicine by patients until primary care overtook that specialty a few years ago, Harvard's Dr. Ateev Mehrotra and other researchers found in a recent study of claims data from a large insurer.

Research firm IHS Markit estimates that telemedicine visits in the U.S. will soar from 23 million in 2017 to 105 million by 2022. But even then, they will probably amount to only about one out of every 10 doctor visits, said senior analyst Roeen Roashan.

MDLive CEO Rich Berner said telemedicine is like the digital video recorder TiVo, which took a while to catch on with viewers.

"People were so used to doing things the other way that it just took a little while to kind of really go mainstream," he said. "But when it did, it went mainstream big-time."  (AP)

Hospital: Doc gave near-death patients excessive pain meds

The main entrance to Mount Carmel West Hospital is shown Tuesday, Jan. 15, 2019. An intensive care doctor ordered “significantly excessive and potentially fatal” doses of pain medicine for over two dozen near-death patients in the past few years. (AP Photo/Andrew Welsh Huggins)

Kantele Franko

Columbus, Ohio (AP) - An intensive care doctor ordered “significantly excessive and potentially fatal” doses of pain medicine for at least 27 near-death patients in the past few years after families asked that lifesaving measures be stopped, an Ohio hospital system announced after being sued by a family alleging an improper dose of fentanyl actively hastened the death of one of those patients.

The Columbus-area Mount Carmel Health System acknowledged the doses were larger than needed to provide comfort for dying patients. That raises questions about whether there was an intentional or possibly illegal use of the drugs to accelerate deaths.

The system said it has fired the doctor, reported findings of an internal investigation to authorities and removed 20 employees from patient care pending further investigation, including nurses who administered the medication as well as pharmacists.

Mount Carmel said the situation came to light because an employee reported a safety concern. The health system shared no information about what might have prompted employees to approve and administer the excessive dosages.

“Regardless of the reason the actions were taken, we take responsibility for the fact that the processes in place were not sufficient to prevent these actions from happening,” Mount Carmel President and CEO Ed Lamb said in a video statement. “We’re doing everything to understand how this happened and what we need to do to ensure that it never happens again.”

The attorney who brought the lawsuit said, in that case, either layers of safeguards repeatedly failed to flag a “grossly excessive” dosage of fentanyl, or the medical professionals intended to accelerate the death of the patient, 79-year-old Janet Kavanaugh.

“On balance, it’s hard to believe the former occurred rather than the latter. ... This is not just a simple situation of an error,” lawyer Gerry Leeseberg said.

The lawsuit was filed in Franklin County against the health system, a pharmacist, a nurse and the doctor, whom it identifies as William Husel.

Case records listed no attorney yet to comment on Husel’s behalf. There is no public personal phone listing for him, and other numbers linked to him weren’t accepting calls Tuesday.

Husel’s case emerges amid a national debate over physician-assisted death. In such cases, physicians prescribe medications in life-ending amounts to terminally ill patients.

Five states - California, Oregon, Vermont, Washington and Colorado - allow the practice, and 20 have considered but not passed legislation to do so, according to the nonpartisan National Conference of State Legislatures. A Montana court also legalized it there, though there’s no regulatory framework in place. In Ohio, the practice remains illegal. A bill that would have allowed terminally ill, mentally competent patients to self-administer a prescription to end their lives failed to gain traction in the last legislative session.

But Joe Carrese, a faculty member at the Johns Hopkins Berman Institute of Bioethics, said that such laws are carefully crafted. He said that if Husel administered lethal quantities of drugs to unwitting patients in order to end their lives, his acts didn’t meet the definition of physician-assisted death.

“In this case, if that was the intent, this was essentially euthanasia, which is not legal anywhere in the United States and not at all the same as physician-assisted death,” he said.

Franklin County Prosecutor Ron O’Brien confirmed that his office has met with doctors, hospital executives and attorneys and that an investigation is underway, but he wouldn’t discuss details. He said they’ve received cooperation from Mount Carmel, which operates four hospitals around Columbus, and from parent organization Trinity Health, one of the country’s largest Roman Catholic health care systems.

Records show the State Medical Board in Ohio has never taken disciplinary action against Husel. It’s unclear whether that board ever received a complaint or conducted an investigation about him, as such records are confidential under Ohio law, and outcomes are made public only if the board takes formal action.

Husel was a supervised resident at the Cleveland Clinic from 2008 to 2013, according to a statement from the medical center. It’s now conducting an internal investigation of his work, but it said a preliminary review found that his prescribing practices were “consistent with appropriate care provided to patients in the intensive care unit.”

Carrese, from the bioethics institute, commended Mount Carmel for encouraging a culture in which medical staff and other employees can come forward without fear, but he said the extent of the allegations is concerning.

“The fact that there may be other patients, up to 26 other patients, really calls into question whether the culture of safety and reporting that they’re shooting for, whether there’s more work that needs to be done,” he said.

The allegations carry echoes of prior Ohio cases in which patients were killed.

Nurse’s aide Donald Harvey, dubbed “the Angel of Death,” claimed responsibility for killing more than 50 people in Cincinnati and Kentucky hospitals during the 1970s and ’80s, mostly by poisoning. Many were chronically ill patients, and Harvey claimed he was trying to end their suffering.

Admitted serial killer Michael Swango, the former physician dubbed “Dr. Death,” pleaded guilty to killing four people, including one while interning at an Ohio State University hospital, and was believed to have poisoned dozens as he moved between hospitals in various places.

Leeseberg, the attorney in the Mount Carmel lawsuit, said an important difference in this case is that multiple people were involved in the patients receiving the drugs.

“The pharmacist has an obligation to question an order, and the nurse has an obligation to question the order as well,” Leeseberg said. “All of those safeguards were overridden or ignored. It’s like nothing I’ve ever seen.”

Companies navigate dementia conversations with older workers

Mary Radnofsky, diagnosed with a rare form of leukoencephalopathy and in the early stages of dementia, tries to recall a recent phone conversation in her home on Friday, Jan. 18, 2019, in Alexandria, Va. Faced with an aging American workforce, U.S. companies are increasingly navigating delicate conversations with employees suffering from cognitive declines or dementia diagnoses, experts say. (AP Photo/Kevin Wolf)

Andrew Soergel

Chicago (AP) – Faced with an aging American workforce, companies are increasingly navigating delicate conversations with employees grappling with cognitive declines, experts say.

Workers experiencing early stages of dementia may struggle with tasks they had completed without difficulty. Historically punctual employees may forget about scheduled meetings. And those who have traveled to the same office day after day, sometimes for years on end, may begin to lose their way during their morning commutes.

“I’ve talked to a number of families where a person didn’t realize they had the disease and they didn’t know what was going on. And they got fired for performance issues before anyone knew what the diagnosis was,” says Ruth Drew, the director of information and support services at the nonprofit Alzheimer’s Association. Drew also oversees the organization’s 24-hour help hotline.

The Bureau of Labor Statistics estimates the number of U.S. workers between the ages of 65 and 74 will balloon 55 percent between 2014 and 2024, with 86 percent growth for the working population over 75.

It’s that 65-and-up age group that’s most likely to face dementia diagnoses, though early-onset symptoms can afflict younger people. And even though studies show the rate of dementia diagnoses has actually fallen in recent years, the sheer number of older U.S. workers expected to remain in the workforce has increasingly left employees and employers wrestling with the prospect of dementia in the office.

“And it’s not just managing missed deadlines. It’s about managing their frustration with everything that’s changing,” says Sarah Wood, director of global work-life services at Workplace Options, a North Carolina-based consultation and training organization. “If this person has been a dependable employee for 40 years and is now missing meetings, they’ll be beating themselves up over this.

The Americans with Disabilities Act, which guarantees certain rights and workplace accommodation, covers individuals with Alzheimer’s diagnoses and certain other forms of dementia depending on the employee’s position and level of impairment.

“The trick is figuring out what tasks they can still perform and what they can still do safely to continue to contribute,” Wood says.

Possible accommodations might include issuing written instructions rather than verbal commands, or reassigning a heavy machine operator or employee to a desk job, says David Fram, director of Americans with Disabilities Act and equal opportunity services at the nonprofit National Employment Law Institute. He notes that employers cannot simply fire an employee solely because of a disability or dementia diagnosis if that person can still perform certain job requirements.

“The next question is whether they’re qualified for their job. And that’s the tougher point, depending on how advanced (the dementia) is,” he says. “People have to do the essential functions of the job.”

This creates a delicate balance between employer and employee. For some, disclosing dementia to an employer could open the door to workplace adjustments. For others, there’s fear of stigmatization or even termination.

Mike Belleville, 57, a former telecommunications technician at Verizon now living in Bellingham, Mass., was diagnosed with Lewy body dementia in 2012.

He said receiving his diagnosis “was almost like, ‘Hey, here’s what’s wrong with me. And here’s the reason why I’ve been messing up.’”

Belleville says his “aha” moment came when his performance began to slip and younger colleagues he initially trained began coaching him through his job.

He says he wouldn’t have had access to certain benefits like short-term disability insurance had he not fully disclosed his condition to his employer. His supervisors eventually scaled back his hours and reduced his workload, allowing him to work several months with a regular salary before going on disability leave.

“If you’re driving a semi cross-country and you keep getting lost, OK, you shouldn’t be doing that. But could you work in the loading dock? Could you have a desk job? What are the ways we can accommodate people so that they can continue contributing meaningfully to society?” asks Al Power, an internist and geriatrician who has extensively researched and written about dementia.

After initially being misdiagnosed, Mary Radnofsky, 60 and a former professor now living in the Washington, D.C., metropolitan area, learned she had a rare form of leukoencephalopathy, which caused minor strokes, seizures and cognitive impairment.

Her worsening condition led her to step away from her teaching career at the University of Hawaii in 2011, even before her official diagnosis.

“Apparently I ‘looked’ healthy both on paper and in person, had a very good education, and was ‘too young’ to have dementia,” she says.

Early dementia symptoms often mirror other ailments that may impair cognitive function, or even other types of dementia. Belleville, for example, was initially diagnosed with early-onset Alzheimer’s before doctors recognized his condition as Lewy body dementia.

Muddling matters further are instances in which patients plead with their doctors to run more tests or cushion the severity of their symptoms in medical reports, says Rod Blough, a former human resources executive at Luxottica who at 58 years old was diagnosed with early-onset Alzheimer’s disease and Lewy body dementia.

“If a patient is adamantly opposed to having a certain diagnosis, they might be able to influence a certain doctor not to put that language into their medical record. And that can help you on the employment side,” he says. “If your employer wants to see medical documentation, you can show them papers that suggest you’re still well enough to work.”

Blough notes that this may not be the best option for employees long-term, considering their access to Social Security Disability and other resources will be influenced by possibly inaccurate medical documentation. But he says dementia sufferers’ decisions about whether to remain in the workforce are often very personal. 

Power, the geriatrician, suggests that the U.S. is “still in denial in terms of public policy” related to the aging workforce and supporting employees with dementia. And that, he says, has placed a “greater burden on society.”

“I don’t think people have gotten their heads around how to respond to this rapidly aging population,” he says. “We should have been planning for this 30 years ago.”

AP-NORC Poll: Edit baby genes for health, not smarts

In this Oct. 9, 2018 photo, an embryologist adjusts a microplate containing embryos that were injected with gene-editing components in a laboratory in Shenzhen in southern China’s Guangdong province. (AP Photo/Mark Schiefelbein)

Lauran Neergaard

Washington (AP) - Most Americans say it would be OK to use gene-editing technology to create babies protected against a variety of diseases - but a new poll finds they’d draw the line at changing DNA so children are born smarter, faster or taller.

A month after startling claims of the births of the world’s first gene-edited babies in China, the poll by The Associated Press-NORC Center for Public Affairs Research finds people are torn between the medical promise of a technology powerful enough to alter human heredity and concerns over whether it will be used ethically.

Jaron Keener, a 31-year-old exhibit designer at Pittsburgh’s Carnegie Museum of Natural History, said he’s opposed to “rich people being able to create designer babies.”

But like the majority of Americans, Keener would support gene editing in embryos to prevent incurable diseases. His mother has lupus, an inflammatory disease that may have both environmental and genetic triggers.

Lupus has been “a looming presence my entire life. I’ve been around somebody with a chronic illness and I’ve seen the toll that has taken, not just on her life, but the life of my family,” he said.

Gene editing is like a biological cut-and-paste program, letting scientists snip out a section of DNA to delete, replace or repair a gene. Altering adult cells would affect only the patient being treated.

But editing genes in eggs, sperm or embryos would alter the resulting child in ways that can be passed to future generations - a step with such profound implications that international science guidelines say it shouldn’t be tested in human pregnancies until more lab-based research determines it’s safe to try.

The AP-NORC poll shows about 7 in 10 Americans favor one day using gene-editing technology to prevent an incurable or fatal disease a child otherwise would inherit, such as cystic fibrosis or Huntington’s disease.

Roughly two-thirds of Americans also favor using gene editing to prevent a child from inheriting a non-fatal condition such as blindness, and even to reduce the risk of diseases that might develop later in life, such as cancers.

Side effects are possible, such as a gene-editing attempt that accidentally alters the wrong DNA spot, and the poll finds 85 percent think that risk is at least somewhat likely.

But about 7 in 10 Americans oppose using gene editing to alter capabilities such as intelligence or athletic talent, and to alter physical features such as eye color or height.

The poll highlights that if gene editing of embryos ever moves into fertility clinics, there will be some hard choices about what non-fatal disorders should qualify, said Columbia University bioethicist Dr. Robert Klitzman. What if scientists could pinpoint genes involved with depression or autism or obesity - would they be OK to edit?

“It’s one thing to look at the extremes of fatal diseases versus cosmetic things, but in the middle are going to be these very different issues,” Klitzman said.

That reported gene editing in China was an attempt to create babies resistant to HIV infection, a target that many scientists in the U.S. and elsewhere decried because there are effective ways to prevent the AIDS virus.

The poll shows most people think it is at least somewhat likely that gene editing could wipe out certain inherited diseases and lead to other medical advances.

Yet despite the medical enthusiasm, more Americans oppose than favor government funding for testing on human embryos to develop gene-editing technology - 48 percent to 26 percent. About another quarter of the population takes no stand.

Without that research, how could gene editing ever become a choice for families hoping to avoid a disease?

“That’s a good question,” said Keener, the Pittsburgh museum worker, who opposes such funding for fear that research would lead to designer babies rather than fighting disease.

“If there would be a way to narrow the scope of research, I would be OK with government funding,” he said. “I just don’t have a lot of confidence people wouldn’t use it for their own gain.”

Indeed, the poll uncovers a lack of trust in science: About a third think this kind of gene editing will be used before it’s adequately tested, as many scientists say happened in China. Nearly 9 in 10 people think the technology will be used for unethical reasons, including 52 percent who say this is very likely to happen.

And roughly three-quarters of Americans say gene editing probably wouldn’t be affordable for the average person - raising the specter of certain genetic diseases becoming a problem only for the poor.

“People appear to realize there’s a major question of how we should oversee and monitor use of this technology if and when it becomes available,” said Columbia’s Klitzman. “What is safe enough? And who will determine that? The government? Or clinicians who say, ‘Look, we did it in Country X a few times and it seems to be effective.’”


AP-NORC Poll: Most favor gene editing for disease prevention


HEADLINES [click on headline to view story]

Telemedicine's challenge: Getting patients to click the app

Hospital: Doc gave near-death patients excessive pain meds

Companies navigate dementia conversations with older workers

AP-NORC Poll: Edit baby genes for health, not smarts