News&Views

July 24, 2007

Sweet IT report

Not surprisingly, a recent report from the Center for Information Technology Leadership (CITL) takes a very favorable view of using information technology to combat diabetes. The report, The Value of Information Technology-Enabled Diabetes Management,” published last month online but summarized earlier this year in a Diabetes Care article, reviewed the benefits, costs, and quality implications of IT-enabled diabetes management programs, such as electronic diabetes registries and clinical decision support software. It found that all forms of IT-enabled disease management improved patients’ health and reduced costs. Regarding the report’s observed use of HIT in disease management by government/insurance/managed care (payers) more than physicians (providers): “Because cost savings from improved care are largely reaped by payers, many diabetes-management programs are implemented by payers rather than providers. Furthermore, providers have been slow to adopt health information technologies that underpin diabetes management programs. Yet while implementation of payer technologies does improve the health of patients with diabetes and results in cost-of-care savings, providers are in the best position to improve care and control medical costs. This misalignment of incentives may be causing the market to pursue suboptimal interim solutions.” CITL is a nonprofit research center for those who, according to their Web site, “need evidence about the value of specific health information technologies.” It is based at Partners HealthCare System in Boston and is headed by a prestigious high-powered executive committee



July 19, 2007

HIT the Road

Filed under: — mlazoff

A provocative editorial published in the current issue of Modern Healthcare, “Scrap the National IT Plan” was written by Assistant Managing Editor Todd Sloane. From the editorial: “Why is it that nobody in government recognizes that the sharing of any data should be for medical and research purposes only? Until government absorbs this lesson, we shouldn’t have a national IT system…What may be needed now is simplicity, something in short supply when IT experts get together. One thing that stands out is that modest IT success tends to happen in larger, integrated health systems. Doctors operating in small practices, without any formal ties to hospitals beyond admitting privileges, may simply be left behind on the IT front.”



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.”



March 11, 2007

EMIssion highly improbable

Filed under: — mlazoff

The March issue of Mayo Clinic Proceedings published a trio of studies looking into potential electromagnetic interference (EMI) of mobile devices in health care. They found rare instances of interference from mobile devices involving implantable cardioverter defibrillators and electrocardiograms outside the hospital setting. Importantly, they found no interference using mobile devices within hospitals, although only a handful of mobile and medical devices were tested. The hospital tests were conducted by the same group who found in 2005 that older analog cell telephones produced the most interference when placed within 3 feet of (also generally older) medical devices. 

The issue’s editorial closes with a summary of current standards and suggestions for the future: “On its Web site (www.fda.gov/cdrh/emc/emc-in-hcf.html), the FDA’s recommendations are more or less generic statements that medical facilities should check their equipment, identify locations where EMI could be problematic (eg, operating rooms and intensive care units), and educate staff. On the basis of the results of the 3 reports in the current issue of Mayo Clinic Proceedings it would be appropriate for the FDA to take a more explicit stand that EMI is unlikely to occur in a hospital setting and that internal regulations in health care facilities should reflect that fact. Recommendations should also reiterate that the risk is not zero and that medical personnel should remain vigilant in order to detect and mitigate the uncommon occurrence of clinically relevant EMI of medical devices.”



March 8, 2007

A mixed performance

Filed under: — mlazoff

Based on General Internists’ Views on Pay-For-Performance and Public Reporting of Quality Scores: A National Survey published in the March/April issue of Health Affairs and reported yesterday in iHealthbeat and GovernmentHealthIT articles, over 75% of randomly selected general internists surveyed support financial incentives from government and/or health payers to improve care. According to these articles, for Lawrence Casalino, MD, PhD, the lead investigator and an assistant professor of health studies at the University of Chicago, the strong support for pay-for-perfomance was a surprise, and a positive sign for health IT adoption. Yet less than half of physicians surveyed support public disclosure of quality scores from medical groups, and even fewer support public reporting of scores from individual physicians, even if the results reflect quality care accurately—which most believe will not be the case anyway. 



February 13, 2007

Ranking Relevancy

Filed under: — mlazoff

A new interface for Medline searches, ReleMed ranks citations based on the proximity of search terms to one another in adjoining or nearby sentences, brings up selected sentences from the article with the search terms highlighted, and links to the PubMed citation. Read more about it in Relemed: Sentence-level Search Engine With Relevance Score for the Medline Database of Biomedical Articles from last month’s BioMedCentral open access journal, BMC Medical Informatics and Decision Making. ReleMed is a gift from Mir Siadaty, MD at the Department of Public Health Sciences, University of Virginia School of Medicine.



Tooting their own horn

Filed under: — mlazoff

Missing from among the initiatives on Health and Human Services (HHS)’s Health Information Technology list of Major HIT Accomplishments: 2004-2006 is the creation of their much improved Web site.

The list provides a nice review of past major government initiatives and, more important, what projects the federal government will support in 2007 and beyond. Leading the list is the National Healthcare Information Network, followed by future recommendations from HHS’s advisory board, the American Health Information Community; and the coordination of state with federal laws on privacy and security of patient data. Details on each can be accessed from the site’s left navigation panel.



January 30, 2007

The NEPSI Challenge

Physicians who already signed up for the free Web-based e-prescribing software eRx NOW, provided by the National e-Prescribing Patient Safety Initiative (NEPSI), will begin receiving their free software tomorrow (January 31). According to their online FAQs, NEPSI  is a coalition of large corporations led by Allscripts and including Dell, Google, Microsoft, Intel, SureScripts, among many others. NEPSI sponsors are investing $100 million over the next five years to provide free Allscripts’ e-prescribing software to every U.S. physician as a way to jumpstart the use of e-prescribing software, and eventually electronic medical records, to reduce preventable medication errors and overall health care costs. NEPSI says,”We are not trying to lock providers into a one-vendor solution – we have a solution that works with any Electronic Health Record, Personal Health Record or practice management system from any vendor certified by the Certification Commission on Healthcare Information Technology (CCHIT).” For more information from NEPSI, see the press release from earlier this month.

From ”Coalition Offers Doctors Free Electronic Prescriptions,” an article posted two weeks ago on Ziff-DAvis’ eWeek: “The [NEPSI] system will be able to transmit prescriptions electronically to over 95 percent of the nations’ pharmacies. Two of the health insurance companies in the coalition, Aetna and WellPoint, said that they would provide incentives for physicians to write electronic prescriptions. Another coalition member, Sprint Nextel, is offering free pocket PC phones to doctors who sign up early…The initiative is offering a free Web-based system that would instantly check prescriptions for interactions with other medications (powered by a database provided by Wolters Kluwer Health) and would also check how much a patient or plan would have to pay for a drug. Google is providing a custom search engine to help physicians find relevant information for themselves or patients. Patient information will be stored remotely so that it will not be compromised if a doctors’ phone or computer is stolen.” 

This is not the first such effort. The article recalls how, in 2004, one coalition member—health insurer giant Wellpoint—invested $42 million in an effort to provide free e-prescribing software. “Doctors took the free stuff, but did not use it for the intended purposes. Since then, however, health IT evangelists have made large headways to create more positive attitudes toward health IT. ”

That same year, a second e-prescribing initiative involving many of the same NEPSI founders, Cafe Rx, also dissolved. Digital Healthcare & Productivity’s article, Free ePrescribing S/W Initiative Stirs Interest and Debate, goes into greater detail regarding Cafe Rx and quotes several competitors who speculate regarding NEPSI’s ulterior motives, along with replies from Glen Tullman, Allscripts CEO. “Tullman is clear that neither Google nor anyone else will mine data collected as part of the eRx NOW program and use the results for marketing purposes. ‘Patients and physicians will have unique access to all the information…Google will have no access to data we receive as part of the electronic prescribing process.’ Other questions raised about the e-prescribing program focus on accessibility of patient demographics and drug formularies. Notably absent from the list of NEPSI sponsors and supporters was RxHub, a joint venture of major pharmacy-benefit management companies that provides real-time electronic connectivity to patient-specific formulary and drug-benefit information. Tullman acknowledges that many users would have to find a third party to link the prescribing software to existing practice management and billing systems, but says that eRx NOW follows established standards to make the link. ‘We’re happy to interface with any practice management system.’ Tullman also addressed the formulary question by saying that Allscripts has access to eligibility and preferred-drug lists of more than 95 percent of payers nationwide via SureScripts and through the company’s own business relationships. He said that Allscripts was having discussions with RxHub and with practice management vendor Per-Se Technologies—now a part of McKesson due to an acquisition that closed last week—to find ways to pre-populate eRxNOW.”



January 2, 2007

Brailer on Health IT

Before the holidays, the former National Coordinator for Health IT David Brailer, MD, gave an interview for iHealthBeat, the news digest of the California HealthCare Foundation. The full interview, released today, is available as an audio file (excerpts above, downloadable mp3 file below) or a PDF transcript.

From the interview:

  • “I always told people that the battle over health IT adoption was over. It was just a matter of time. The real fight, and this one I don’t have such optimism about, is the fight over patient centricity, or patient control of their health care, and, therefore, control over their health care information…And that’s not so much a health IT battle. That is a battle over the heart and soul of who owns controls and who sets the priorities for the health care system.”
  • “I think we don’t have the right privacy and security regiment. The one that we have under HIPAA and state laws was created largely in a world that didn’t anticipate electronic information that was stored for, or by, or used on behalf of the patient…And I think the American public has been very clear that they want to see privacy protections in place before they’re really willing to jump into [electronic medical records].”
  • “…incentives for adoption [of health IT]. We had the one-year fix to the sustainable growth rate…which gave physicians a bonus for submitting quality data. That has no effect whatsoever on health IT adoption. So it’s time to come back to the question that we’ve put aside during the whole pay-for-performance discussion for three years about the market incentives and the policy incentives to bring us into full adoption of electronic records. I, as a very keen supporter of incentives, withheld my judgment on that during the pay-for-performance period. I think it has now had its chance, and it hasn’t been able to deliver a policy with the impact that I think convinces me that it’s going to help us with adoption, particularly among doctors in rural areas, in a safety net and even small practices.”
  • “Well, I think the change…comes from every place but Washington…in states and in the private sector…I see states moving quickly, and they will do more in 2007 to create a more fertile environment for health IT.”
  • “But I think the promise of personal health information being shared goes beyond a record. I’m particularly excited by remote monitoring, remote patient management; things where it’s not just a static database but where we’re monitoring someone in their home so they don’t have to be in a nursing home or where someone can be monitored in an ICU bed and a doctor doesn’t have to be present all the time but can be tele-present…That is the same concept of a personal set of health information that is centered around the person, but it probably doesn’t meet our definition of what we would call a PHR today. I view more convergence happening between that concept of the database and the streaming set of information, as we really ask the questions about what problems the PHR solves or what opportunities it creates. I think as we start thinking that way, we will come back to this set of functional tools that help us improve the patient role in health care, just like health information has helped us in traditional care delivery beyond the electronic health record — medication administration, reduced errors in inventory management, the way communication occurs, let alone computerized physician order entry. These things that are unheralded heroes of how IT does help are a broad bundle of change, and I think you’ll see that on the personal side as well.”
  • “I think there are two subdebates that will play out, so it creates kind of a two-by-two table with four outcomes. The first one is whether we will go beyond all of the lip service. The patient should be in control of the health care system, in control of their care. They should have information to make treatment choices. They should have information to make a choice about a doctor. They should have the information to be able to make tradeoffs when it comes to various outcomes. And I think this is quite pronounced as we start thinking about the genomic world, where you have so many genomic risks, like, you know, you might have heart disease in the future, or you may have breast cancer, or you may have memory loss. And you have to decide if you’re going to act on that 20 or 30 years in advance. This question about whether we are going to move beyond the promise and actually make the health care industry centered on that, which is profoundly disruptive to the established interests that rely upon a very high volume of hospitalizations, or bouncing patients around, and churning patients a lot because we can’t quite create integrate care processes around them, you know, that’s disruptive. And I think that’s a debate about how far the industry will come towards focusing on patient control and consumer choice. And so you could think about that as either happening or not.
           Secondly, and I think apart from that, there’s a debate about the role of government. We’re sitting in a hybrid system now. Government intrusion in private sector, or participation — neither one is dominant and neither one has the leverage to make it cohesive. The industry can’t do what it’s done in other industries, which is squeeze out the inefficiencies and create, really, a seamlessly integrated experience. Look at the financial sector, elsewhere. Nor can government do this because it doesn’t have control, and I think it has a lot of conflicts of interest with respect to how to make health care work versus the Medicare Trust Fund be solvent. And so you see kind of that being … now sitting at a point of maximum agony. I think that’s going to flip one way or the other. So we could have a very government-controlled system that’s consumer responsive or a government-controlled system that is quite provider-driven, and we could have a private-sector system that’s one or the other.”


December 4, 2006

IT Phone Home

Filed under: — mlazoff

Use of Mobile and Wireless Technology Jumps in Hospitals, according to an article posted two weeks ago in Digital Healthcare and Productivity.com (the new name for Healthcare IT World News). “Even though adoption of electronic health records (EHR) and other clinical IT remains fairly anemic, at least one aspect of health-IT has taken giant steps forward in the last few years: the use of mobile and wireless technology where choices are proliferating.” Mobile technology here are essentially PDA smart phones with built-in Wi-Fi or Bluetooth wireless functionality. Technology has improved over just the past few years; according to the article, the time it takes to download images has decreased from 30 seconds to 3 seconds. Although screen size and resolution on these devices still do not allow for quality graphics, the article quotes several physicians who state that consulting on emergency conditions does not generally require subtle findings in CT scans or EKGs. The article goes on to describe upgrades in the major wireless networks, and how local area networks (LANs) such as Wi-Fi hot spots are bridging technology gaps. Specific LANs operating in hospital complexs are also described.

“And there’s another side benefit of the mobile devices. ‘Our kids, in particular, just love us carrying around our iPaqs,’ says [Julie] Massey, MD, a pediatrician.”



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