News&Views

October 9, 2007

Microsecurity on Microsoft’s HealthVault?

Filed under: — mlazoff

Last week, Microsoft unveiled HealthVault, the highly promoted collection of next-generation (Web 2.0) consumer health-related projects. Online now is a personal health records (PHR), which allows for traditional data storage within a consumer-controlled portal through which Microsoft-partnered doctors, clinics and hospitals can, with patient permission, also view the PHR and communicate information and test results back to the patient. According to a New York Times article from October 4th, Microsoft Rolls Out Personal Health Records, “The organizations that have signed up for HealthVault projects with Microsoft include the American Heart Association (AHA), Johnson & Johnson LifeScan, NewYork-Presbyterian Hospital, the Mayo Clinic and MedStar Health, a network of seven hospitals in the Baltimore-Washington region. The partner strategy is a page from Microsoft’s old playbook. Convincing other companies to build upon its technology, and then helping them do it, was a major reason Windows became the dominant personal computer operating system.” The article provides examples of several corporate collaborations: an online blood pressure management tool created by Microsoft and the AHA where data can be entered by patient or physician; a glucose monitoring tool for diabetics who use Lifescan meters; and how patients within partnered healthcare systems can receive and store test results, such as their EKGs. 

A second site feature provides access and storage facilities to selected consumer health information using their clustering HealthVault search engine, now in beta testing. Microsoft states that all searches are anonymous. The results page includes Sponsored Results. For more information, see Microsoft Debuts HealthVault, an article posted the same day on Digital Healthcare and Productivity Web site.

Privacy issues on PHRs and associated features are addressed. According to the article, ”Microsoft’s privacy principles have impressed Dr. Deborah Peel, chairwoman of the Patient Privacy Rights Foundation, a nonprofit group. In terms of patient control, and agreeing to outside audits, ‘Microsoft is setting an industry standard for privacy,’ said Dr. Peel.”

A news release on the Foundation’s Web site announces that Microsoft “sought advice” from the Foundation in preparing HealthVault and that Dr. Peel appeared with Microsoft at the press conference announcing its launch. ThePrivacyPlace.org, a multi-institution academic research technical privacy center without known relationship to Microsoft, today posted an article on their Web site questioning Is The Vault Really Protecting Your Privacy? ”When the Health Insurance Portability and Accountability Act (HIPAA) was enacted, we did not envision that private software firms would eventually want to create databases for our health records. As a result, HealthVault and other PHR systems are not subject to the same privacy and security laws to which traditional medical records are subject to in the United States because they are not ‘covered entities’ as specified in the HIPAA…Microsoft appears to have sought the counsel of physicians [Dr. Peel] who believe that patient consent is the best indicator of privacy protections. Unfortunately, most physicians do not understand the subtleties buried within healthcare privacy statements within the context of the software that implements those statements…The hype surrounding HealthVault’s privacy protections among those in the medical community must be balanced with the reality of the information security and privacy practice expressed in its public privacy statements.”



September 11, 2007

The Eyes Have It

Filed under: — mlazoff

An interesting opinion piece by medical resident Michael Hochman, MD, posted today on Boston.com, Eyes Shift From Patient to Keyboard reviews some of the benefits and limitations to physicians in using computers in patient encounters. Benefits include: speed of chart review, increased access to key medical history information, and at least one study that found ”after the introduction of a computer in the office, patients were more likely to feel that their doctors were familiar with their history.” On the other hand, two studies found that a sizeable minority of patients experienced computers as interfering with their time with, and attention from, the doctor. In particular, lack of eye contact between physician and patient is discussed, along with possible remedies, such as acknowledging the distraction to the patient beforehand, and closing each session with a face-to-face review of the visit. Another option not discussed: arranging the monitor so that both patient and physician can see what’s on the screen, as when the patient sits alongside rather than across from the physician’s desk. 



September 6, 2007

P4P’s peek into the future of medical charting

The Leapfrog Group, a powerful group of major company and other large private and public healthcare purchasers known for supporting quality and cost-control incentives, promotes the results of this year’s Pay for Performance (P4P) and Consumer Incentive Survey of 75 “purchasers, government agencies, and health plans”. Conducted biannually since 2003, this year Leapfrog partnered for the first time with the P4P specialty software company Med-Vantage. The actual results are not online, only the press release, which describes several statistics: a nearly four-fold increase in the number of P4P programs to a current 148; a cost savings noted by about a third of respondants; and that provider performance was made publicly available by over 30% of respondants. 

An article posted earlier this week on the Web site of magazine Modern Healthcare Online commented on this press release: “Even as payers issue glowing news releases about the expansion of their programs’ scope and the millions of dollars in physician rewards they’re dispersing, government officials, research organizations and physicians are questioning the motivation and methodology of current pay-for-performance programs.” The above Leapfrog/Med-Vantage survey is contrasted with a report on P4P among commercial insurers released several weeks ago by PriceWaterhouse, which describes significant differences among these programs’ structures, performance metrics and rewards structures. 

The Modern Healthcare article quotes a surgeon/attorney who describes P4P as, “an attempt to control prices—but not for the benefit of the patient or the benefit of the doctor.” From elsewhere in the article: “Meanwhile, the physician-ranking programs [used by over 30% of respondants to the Leapfrog/Med-Vantage survey] under consideration for use by insurers Aetna, Cigna HealthCare and UnitedHealth Group have come under scrutiny by New York State Attorney General Andrew Cuomo, who expressed concern that the rankings may be used to steer patients toward less-expensive rather than higher quality providers.”

HIT is the elephant in the P4P room. According to the Modern Healthcare article, “In the end, the one industry segment that may truly be happy with pay-for-performance programs are health IT vendors who can persuade providers that their electronic systems are absolutely necessary for the data management that require such programs.” The article closes with a comment by a Pricewaterhouse director who believes that wider IT adoption would “‘pave the way for standardized measures,’ mak[ing] it easier to validate physician data and reduce the administrative costs of the programs.” The Leapfrog/Med-Vantage press release agrees: ”Advanced P4P programs are now developing tools to measure improvements in outcomes and eligibility for rewards directly from medical charts.”



August 30, 2007

Chart Review

Filed under: — mlazoff

Patient Records Needs Review is the cryptic title from a Wall Street Journal article that advises everyone to review their own medical records for errors, miscodings, outdated diagnoses, and other inaccuracies. ”Savvy consumers know to check their credit score before applying for a loan. What is less well known is that consumers can improve their chances of getting insured — and of paying lower premiums — by checking that medical information held by doctors, hospitals and pharmacies is accurate…the U.S. health-care system relies mainly on paper records, which make it harder to coordinate care and spot errors.” The article closes with a big nod to EHRs: ”…until the U.S. develops a comprehensive, consolidated [electronic health records] system, the burden falls to individuals to keep tabs on their health histories.”

The article quotes Joy Pritts, research associate professor at Georgetown University’s Health Policy Institute and founding director of their Center of Medical Record Rights and Privacy.  



August 19, 2007

Show me the money!

A Web-exclusive article in last week’s Newsweek wonders What’s Holding Up the Digital Revolution? Concerns over patient privacy and lack of evidence-based quality issues are mentioned, but the article focuses on the high cost of setting up and maintaining electronic records, which are estimated here to cost about $100,000 for an individual practice and more than $50 million for a large hospital. Lack of capital is encouraging the formation in the U.S. of a two-tiered system, where electronic implementation of medical records has mostly been limited to the nation’s larger, better-funded medical centers.  According to the article, “many doctors worry that small hospitals and individual practices—which deliver roughly half of the country’s medical care—could fall further and further behind, either because they can’t afford to go digital or because the cheaper systems they do have money for aren’t good enough to make a difference [in quality or cost of patient care].”  HHS Secretary Mike Leavitt believes that the health care industry should shoulder these costs, not the federal government, though others quoted in the article disagree. The Newsweek article does not mention technology issues that others believe are also threatening the implementation of Bush’s mandate for electronic records throughout the U.S. by 2014..



July 26, 2007

Phlaunting PHRs

A July 17th press release by Aetna underscores the current push for patients to use personal health records (PHRs), by government, private insurers, large employers—even Google

The promises of a patient-centric healthcare system where medical information is easily accessible by all and patients are full participants in their care, as exemplified by PHRs, is balanced by concerns over privacy of personal data, lack of medical record interoperability, potential disruption in the physician/patient relationship, confusion over definitions and goals of PHRs, and lack of evidence demonstrating their efficacy and improved quality care. For those interested in learning more about PHRs, the independent philanthropy California Healthcare Foundation published Perspectives on the Future of Personal Health Records last month. The report provides a forum for six computer-literate healthcare and legal professionals to share their knowledge, fears and visions on PHRs.  



July 19, 2007

primarycaredoctor@computer.net

Patient Access to an Electronic Health Record (EHR) With Secure Messaging: Impact on Primary Care Utilization” from the July issue of American Journal of Managed Care is self-described as “the largest study to date of the impact of access to secure patient–physician messaging on provider workload.” This retrospective study was conducted from 2002-2005 at the nonprofit managed care Kaiser Permanente Northwest (KPNW). It looked at nearly 4700 patients who were already active enrollees in HealthConnect Online service (which provides patient access to limited sections of their EHR and secure emailing) with 3200 of them also matched by age, sex, selected chronic conditions and primary care physician to a control group. They found a 6.7% drop in office visits (p<0.003), and almost 14% drop in phone calls (p<0.01) among HealthConnect Online participants as compared to controls. The authors conclude that, “Electronic messaging may provide a solution to pervasive efficiency and access issues for both patients and providers.” There is no mention of resultant changes in quality of care other than this taste: “KPNW collects data for the Health Employer Data and Information Set (HEDIS) as part of routine quality surveillance. The HEDIS reports for HbA1c testing did not vary to a statistically significant degree during the years under observation,” and there is no mention of broad patient satisfaction or changes in physician income. Modern Healthcare made this observation in their writeup: “Naturally, because Kaiser is an integrated delivery network, officials there can look upon technology driving a near-10% drop in office visits with far more equanimity than a fee-for-service physician group leader would.”



July 15, 2007

Quality Care by MDs, not EHRs

According to “Electronic Health Record [EHR] Use and the Quality of Ambulatory Care in the United States” from the July 9th issue of Archives of Internal Medicine, using EHRs in the out-patient setting does not appear to improve quality of care (as measured by compliance with 17 ambulatory care quality indicators developed at Stanford University). The retrospective study analyzed data drawn from the 2003 and 2004 National Ambulatory Medical Care Survey, an annual survey conducted by the CDC’s National Center of Health Statistics. During these two years, 18% of physician visits used EHRs and, when compared to physician visits without EHRs, the investigators found no statistical difference among the outcomes in 14 of 17 indicators.  
          Jeffrey Linder, MD, lead author and general internist at Harvard’s Brigham and Women’s Hospital, explained in an associated iHealthBeat article that, “…other studies have shown that [EHRs] are not much more than a replacement for the paper chart. In light of those findings, this is not that surprising…” Randall S. Stafford, MD, PhD, senior author and associate professor of medicine at the Stanford Prevention Research Center, offers his theories on why EHRs were not found to improve quality care: the study looked at older systems that probably lacked clinical decision support, and that “No matter how sophisticated the system, it can’t dictate a course of action to a physician…” For more on how the authors interpreted their study, see Stanford University’s press release. (Ed. note 07/19/07: For a different spin, see WSJ Health Blog’s Computerized Medical Files Not Much Better Than Paper, and the comments that follow.—ML)



July 9, 2007

Web Developers iPhoning In

Filed under: — mlazoff

iPhone physicians looking for ways to extend the smartphone’s clinical functionality may appreciate Apple’s Optimizing Web Applications and Content for iPhone. Web site or Web-based applications can be developed using Apple’s browser Safari Web kit engine, then accessed using the iPhone (or any Web-accessible device that uses Safari, including desktop computers).  



May 31, 2007

EHR data-sharing…not

Filed under: — mlazoff

The business technology magazine Information Week’s recently published article, Why Progress Towards Electronic Health Records (EHRs) is Worse Than You Think, provides a computerphile’s perspective on medicine’s slow adoption of health information technology (HIT). ”Despite several years of concerted national effort, including President Bush’s rallying cry in 2004 to get most Americans on e-health records by 2014, the use of digital records is at a precarious place. Just 10% of doctors’ offices use them. And while hospitals are expanding their use, the most difficult work—the exchange of data among health care providers, especially with rivals—has barely begun. Technology itself has caused problems…[t]here are legal questions, privacy issues, and competitive pressures surrounding the technology, as well as concerns about return on investment. And data-sharing practices have yet to be widely tested in the real world…There’s the occasional clear success, like a long-running Indiana data exchange. There’s also growing interest among big employers to give personal health records to their employees, though it’s not clear how those private efforts will mesh with the efforts of regional health information organizations, known as RHIOs.”

The lengthy, sober article goes on to discuss the technology and financial issues that plagued the failed RHIO in California’s Santa Barbara County Care Data Exchange; the success of Indiana’s over 30-year-old centrally administered RHIO and the newer Massachusette’s peer-to-peer network RHIO; the data sharing and EHR efforts from already-integrated health systems such as Pennsylvania’s Geisenger Health, and Kaiser Permanente; and the hope for several new projects throughout the country. The article notes that the high cost of implementing EHRs is being addressed by the federal government. Not everyone  interviewed for the article agrees that financial incentives alone will overcome the lack of urgency and unwillingness to share data that currently hampers the widespread adoption of EHRs by physicians.  

The article shares some predictions. “While it’s good for people to use personal health records they create or employees provide to guide their care, [Karen] Bell [MD, Director, Health IT Adoption, Office of National Coordinator for HIT] says, the biggest benefit comes from doctors having data access to reduce mistakes, eliminate costs such as redundant tests, and improve quality of care. But don’t hold your breath. ‘It’ll be a good 10 to 15 years before we see volume’ adoption by doctor practices, Bell predicts.” 



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