News&Views

July 31, 2007

Secret Search

Filed under: — mlazoff

Not specifically for physicians, and no real secrets revealed, but a nice list of Web resources useful in How to Vet an Expert (and anyone else, for that matter). From BullsEye, a newsletter distributed by the expert witness and litigation consultant firm IMS ExpertServices. 



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 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 25, 2007

No smiley face for rating systems

Filed under: — mlazoff

An article in today’s Washington Post, Doctors Rated but Can’t Get a Second Opinion: Inaccurate Data About Physicians’ Performance Can Harm Reputations, ”raises questions about the line between responsible oversight and outright meddling in the relationship between caregivers and their patients.”

The journalist discusses the benefits and problems with computerized rating systems, which are currently used by more than 100 insurance industry markets or regions across the country, including the entire state of  Massachusetts. “Physician profiling relies on the growing practice of creating electronic medical records. Once kept only on paper, records about patients, doctors, hospitals, pharmacies and other caregivers are increasingly aggregated in giant digital storehouses…Doctors are rated on standards of quality of care and cost efficiency. An internist, for example, gets higher ratings on quality if he puts his heart attack patients on beta blockers, a medicine that reduces the workload on the heart, or if diabetic patients are tested for blood-sugar control…The systems differ. A doctor who performs well might be awarded stars, a smiley face or a Tier 1 rating. An inferior doctor’s patients might receive higher co-payments, or the physician might be shut out of an insurer’s preferred network…Such data-driven surveillance offers the prospect of using incentives to steer patients to care that is both effective and sensibly priced.” 

Or “steer” patients to neither. The trend towards physician ratings based on performance on selected quality indicators, “which parallels a push by President Bush to promote consumer access to information about health-care quality and cost, has spurred a lawsuit in Seattle, a physician revolt in St. Louis and a demand by a state [New York] attorney general that one insurer halt its planned program.”

 



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 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.)



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.”



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)



New editorial interns to N&Vs

Filed under: — mlazoff

We’re thrilled to have two new editorial interns join our staff! Naomi Levinthal and Russ Hinz are both currently enrolled  in the Masters of Medical Informatics program at Northwestern University. They will contribute N&V items as part of our editorial process. Look for their work listed under their own category.

Marjorie Lazoff, MD

Editor-in-Chief, News&Views 

 



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