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..

August 14, 2007

Requiem for an HIE Dream

A Health Affairs supplement from earlier this month offers five complementary post-mortems on one of the nation’s most pioneering and visible health information exchange (HIE) efforts: the Santa Barbara County Care Data Exchange or Santa Barbara Project (SBP), which ceased operation this past December after only eight years.

HIEs—advocated in the supplement’s final article by the CEO of the successful Indiana Health Information Exchange (IHIE) as “an essential strategy”—are local information systems designed to share healthcare data among physicians and others providing medical care to community patients. Examples of HIEs include Regional Health Information Organizations (RHIOs) (such as SBP and IHIE), and the CDC’s Public Health Information Network (PHIN). The current vision of the National Health Information Network (NHIN) is as an interconnected string of local or regional HIEs.

The first article, written by Professor Robert H. Miller, PhD (Health Economics), University of California, San Francisco,  tells What Happened to the SBP. The Project began in 1998 as an HIE demonstration experiment proposed by the technology company CareScience (whose CEO at the time was David Brailer, MD, who later became this nation’s first National Coordinator of Health Information Technology) and funded by the independent philanthropy California HealthCare Foundation. The article describes the details of SBP’s early evolution, slow progress, CareScience’s technical difficulties and business upheavels midway through, and SBP’s subsequent revamping and ultimate demise amid legal liability issues and insufficent post-grant funding. 

The rest of the first article, and the other four that follow, propose reasons for SBP’s demise and the lessons learned. ”The main underlying cause [for the Project’s slow progress, according to the first article,] was lack of a compelling value proposition for Santa Barbara [participating healthcare] organizations [and physicians].”  Almost none of the Project’s participants saw medical or financial value in the project, partly because physicians could already obtain electronic patient data using the less extensive and relatively closed Web portals already in place. SBP highlights the lack of efficiency and security inherent in peer-to-peer (Napster-type) design; the importance of active local governance; the need for an incremental series of small successes rather than, as CHCF staff describe in the third article, an “all-at-once” design; and how long-term planning results in a sustainable business model. SBP also demonstrated how HIEs need to be flexible, to change and grow in response to the community and to keep pace with the advances in technology and evolving needs of practitioners and their patients. Even today, and in spite of the advances in technology compared to SBP’s beginnings nearly a decade ago, HIEs are still very much a work in progress, still awaiting practical standards and privacy laws, software advancement and funding options in most communities. 

As Dr. Brailer closes in the second and easily best article of this strong series, From Santa Barbara To Washington: A Person’s and a Nation’s Journal Towards Portable Health Information, ”Thomas Kuhn described in The Structure of Scientific Revolution how the cumulative weight of research and experimentation–whether positive or negative–can hasten the collapse of an existing paradigm. We are in the earliest steps toward major upheaval in the obsolete paradigm of U.S. health care. Health IT is one of the prime forces of innovation and disruption. It will both hasten this change and soften the fall when change does occur. Projects like Santa Barbara—whether they ’succeed’ or ‘fail’—are part of a justified and relentless attack on the status quo of health care amid the unending hope for something better. Without these efforts, the old paradigm will continue, and we will have no chance for meaningful progress.”

August 13, 2007

Safe kids

Using A Computer Kiosk to Promote Child Safety: Results of a Randomized, Controlled Trial in an Urban Pediatric Emergency Department, from this month’s Pediatrics, studied the effects of computers on parental education regarding safety issues in children. The study used Johns Hopkins’ Safety in Seconds program delivered on a  computer kiosk set up in their pediatric emergency department’s waiting room. After answering a few questions on the computer about their beliefs regarding child safety, parents then received a personalized report with ”tailored, stage-based safety messages” on selected topics that was, according to the study’s outcome measures, better read and acted upon by parents as compared to a boilerplate report given to a control group of parents. The patient population in this study was drawn from a lower income urban population, so they may have less access to computers without conveniently located, specially programmed kiosks—and so less access to their health information benefits, particularly the computer’s abilty to easily customize patient education, as this study demonstrates.

August 7, 2007

Cyberchondriac, (don’t) heal thyself

Patients are looking increasingly to the Internet for health information, according to a recent telephone poll of 1,010 U.S. adults conducted in July by Harris Interactive, Inc. Currently, 71% of American adults are what Harris refers to as cyberchondriacs, defined as “anyone who has ever looked online for health information.” As reported in an August 1st article published online at PC World, “Poll Shows Growing Number of Cyberchondriacs,” their numbers have more than tripled since 1998 (the first year Harris conducted the poll) from 53 million to a current 160 million adult Americans. The increase is gaining exponentially too, with a 37% increase in just the past two years. Other key findings: cyberchondriacs “search the Internet about 5.7 times a month to get health information…88% are successful in finding the health information they wanted…about 58% discussed the health information they gathered online with their doctors at least once in the last year, and 55% said they searched for health information based on discussions with their doctors,” up 10% from last year.

According to its director, Harris pollsters coined the term cyberchondriac as a positive reference. ”They’re not second-guessing their doctors, but they’re using a tool that wasn’t available a few years ago. They can get more information and a second opinion.” Dr. Rick Kellerman, president of the American Academy of Family Physicians cautioned that while the searching online for health information can be beneficial to patients and physicians, people have to be careful of Internet sources. In the end, “it may even mean that the need for that personal physician is even more important today than in the past. The problem is there’s so much information overload and you need someone to help figure out what applies to you.”

July 31, 2007

Federal sensors

According to a news release adopted for publication in yesterday’s ScienceDaily, the Department of Defense has awarded a grant to a group headed by The Center for Bioelectronics, Biosensors and Biochips (C3B) at South Carolina’s Clemson University to develop an implantable biochip, “the size of a grain of rice,” that will relay health information from a wounded soldier (or a civilian hurt in an accident). C3B’s director explains, “…first responders to the trauma scene could inject the biochip into the wounded victim and gather data almost immediately. The device has other long-term potential applications, such as monitoring astronauts’ vital signs during long-duration space flights and reading blood-sugar levels for diabetics…We now lose a large percentage of patients to bleeding, and getting vital information such as how much oxygen is in the tissue back to ER physicians and medical personnel can often mean the difference between life and death.

The biochip is estimated to be five years away from human trials. For more information on this potentially revolutionary technology, of which C3B’s in vivo biosensors work is just one example, see the US Department of Energy’s Virtual Poster Presensation on Biosensors and Biochips.

July 23, 2007

A microchip on one’s shoulder

Filed under: — mlazoff

Would Americans sacrifice their anonymity so that their medical information is always available in an emergency? An ABC News article published on their Web site over the weekend, “Chips: High Tech Aids or Tracking Tools?” discusses the pros and cons of implantable microchips with radio frequency identification (RFID) technology. The article describes the technology: “In design, the tag is simple: A medical-grade glass capsule holds a silicon computer chip, a copper antenna and a ‘capacitor’ that transmits data stored on the chip when prompted by an electromagnetic reader. Implantations are quick, relatively simple procedures. After a local anesthetic is administered, a large-gauge, hypodermic needle injects the chip under the skin on the back of the arm, midway between the elbow and the shoulder…The capsules can migrate around the body or bury themselves deep in the arm. When that happens, a sensor X-ray and monitors are needed to locate the chip, and a plastic surgeon must cut away scar tissue that forms around the chip.” Noninvasive tags such as MedicAlert bracelets, currently used by patients with serious allergies or conditions, can be lost even when they are used consistently by the patient.

The relatively lengthy article describes both the technology’s benefits and downsides: “John Halamka, an emergency physician at Beth Israel Deaconess Medical Center in Boston got chipped two years ago, ’so that if I was ever in an accident, and arrived unconscious or incoherent at an emergency ward, doctors could identify me and access my medical history quickly.’ (A chipped person’s medical profile can be continuously updated, since the information is stored on a database accessed via the Internet.) But it’s also clear to Halamka that there are consequences to having an implanted identifier. ‘My friends have commented to me that I’m ‘marked’ for life, that I’ve lost my anonymity. And to be honest, I think they’re right.’”

According to the article, VeriChip Corporation makes implantable microchips for humans; 515 hospitals have opted into its network, but only 100 have actually been equipped and trained to use the system. VeriChip is currently targeting high-risk patients to be tagged. Physicians can purchase a starter kit with 10 microchips and a reader for $1,400. Each patient could be charged $200, an out-of-pocket expense payable directly to the physician since chip implants are not currently covered by private or government insurance. VeriChip currently charges $20 a year for customers to store their blood type, allergies, medications, driver’s license data and living-will directives. For $80 a year, it will store the customer’s full medical history.

(As noted on its Web site but not in the article, Dr. Halamka—who is also Chief Information Officer of Harvard Medical School, Beth Israel Deaconess Medical Center, and Harvard Clinical Research Institute, in addition to Associate Professor of Emergency Medicine—has just joined VeriChip’s Medical Advisory Board.)

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