August 28, 2007

A Health and Human Blog

Filed under: — mlazoff

Earlier this month, Department of Health and Human Services’ Secretary Mike Leavitt started his own blog. In his first entry, Leavitt describes the blog as an experiment that might not last the month due to “time management considerations” — yet since then, he has written volumes about his current trip through Africa. All entries are edited and thoughtful, even though much is also self-promotional, as expected. Almost as interesting are the comments (moderated, of course).

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 16, 2007

Risky Business

The GRAIDS Trial: A Cluster Randomized Controlled Trial of Computer Decision Support for the Management of Familial Cancer Risk in Primary Care, published in the August 14, 2007 issue of the British Journal of Cancer, studied physicians’ use of family history risk assessment software in counselling patients. In this study, researchers in Australia and the UK used the software program, Genetic Risk Assessment on the Internet with Decision Support (GRAIDS). The research team randomized 45 group practices into two sets: one set was trained in the use of GRAIDS, which “links a user-friendly pedigree-drawing tool to patient-specific management advice regarding a family history of breast/ovarian and colorectal cancer, and provides additional numerical risk information about breast cancer.” The control group was trained in the current best practices for genetic referrals. Patients who were found to be at an increased risk in either set were referred to a regional genetics clinic. 

Outcomes were measured at practice, practitioner and patient levels. The trial found that the GRAIDS group both increased the number of genetic referrals, and ensured referrals more closely adhered to official referral guidelines. Additionally the GRAIDS group was able to identify more at-risk patients than the best practices group, and practitioners felt more confident in managing familial cancer. Positive patient outcomes were associated with GRAIDS usage as well; patients who were deemed at-risk in the GRAIDS group reported that they felt less anxious about their risk of cancer than compared to those patients in the best practices group. 

Genetics is increasingly important in clinical medicine, so it is no surprise that family history cancer screening software is being developed in countries throughout the world. For example, the study’s news release reports that Australian government is now funding a national electronic family history tool, based on GRAIDS software. In the United States, the CDC is developing its own software, Family Healthware, to help assess a patient’s genetic risk for coronary heart disease, stroke, diabetes, and colorectal, breast and ovarian cancers. The tool is currently being tested at three academic centers “to determine if personalized prevention messages tailored to familial risk will motivate people at risk to change lifestyle or screening behaviors.” Data collection is expected to be complete by the end of 2007. 

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 10, 2007

Control issues

Filed under: — mlazoff

Retired cardiologist, researcher, teacher and author Richard N. Fogoros, MD’s commentary (on Dr. Scot Silverstein’s Health Care Renewal post regarding the peripheralization of physicians in medical informatics) is an interesting read. Dr. Fogoros closes:

“To reiterate, medical informatics is incredibly important today, because those who control the outcome of the analyses performed therein will (ultimately) control the practice of medicine. Docs are already being trained to accept, as received knowledge, ‘quality’ measures from on-high. Pay for Performance is a major step in that direction. So this is a critical time for those running medical informatics efforts. Precedents are being set (in terms of establishing physician responses to centralized directives) that will probably hold for at least a few generations. If the ‘real’ purpose of Pay for Performance and other physician behavior-mod efforts (efforts that fundamentally rely on medical informatics for their legitimacy) is to control costs rather than to improve quality, you just can’t let doctors run the show. It’s too risky.”

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.”

August 2, 2007

Ordering CPOEs

Two studies in the current issue of Journal of the American Medical Informatics Association (JAMIA) highlight the current frustration with, and potential importance of, computerized physician (provider) order entry (CPOE) systems. The electronic entry of physician instructions for patient care has been touted by the government as a way to reduce medication errors and improve safety, although studies to date have shown mixed results. CPOE has the potential to change patient care, for better or worse, particularly when the ordering process is linked to clinical decision support software, clinical guidelines, and alerts.

Joan Ash, PhD, Department of Medical Informatics and Clinical Epidemiology at Oregon Health & Science University’s School of Medicine, and colleagues followed up their earlier work on unintended consequences of CPOE use at five selected hospitals, with this current study, The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry. Here, they sought to measure the extent and importance of eight of these previously identified types of unintended consequences at every US hospitals with a CPOE system. A total of 176 hospitals completed the telephone survey, a response rate of 47%. Six of the eight types of unintended consequences previously identified by the five hospitals were also considered important by the majority of these 176 hospitals: workflow issues; communications issues; overdependence on technology; never-ending system demands; emotions (usually negative); and more/new work issues. The remaining two types—changes in power structure, and new kinds of errors—identified as important in the preliminary study were not regarded as important with the majority of these hospitals. The authors note an important limitation of their study: they queried individuals who “might have given answers biased in a positive way because they believe in CPOE’s benefits. This might help explain why the two categories of power shifts and new kinds of errors did not rank highly…” The authors’ recommend that hospital leaders charged with implementing CPOE consider each of the eight types of unintended adverse consequences carefully during their planning. “Implementation success depends on managing the unintended, as well as the intended, consequences of CPOE…Unless we make a concerted effort to avoid, manage, and/or overcome unintended consequences, the implementation of clinical information systems may lead to detrimental results.”

Evaluation of Outpatient Computerized Physician Medication Order Entry Systems: A Systematic Review provides a literature review of outpatient CPOE evaluation studies to determine if outcomes exist related to improved patient care. The authors identified 30 such studies, a relatively small number with few if any of them deemed to be well designed. The study’s main finding was that the available evidence does not demostrate that CPOE enhances safety or reduces medication costs, although they did find an increased adherence to clinical guidelines. The outpatient setting presents challenges to CPOE research because inpatient orders tend to be more easily collected and reviewed due to centralized hospital information systems.

As technology advances and the applied research aspects of medical informatics matures, we can hope for better, more clinically relevant studies on software and best-of-breed applications directed at evidence-based practices.

Altered States

Filed under: — mlazoff

The current issue of Nature published a Letter by Nicholas Schiff, MD and colleagues from the Weill Cornell Medical College in New York, which documents the use of a relatively new technology, deep brain stimulation (DBS), to treat a patient with a disorder of consciousness. Behavioral improvement with thalamic stimulation after severe traumatic brain injury and accompanying news articles describe the case of a 38 yo patient with minimally conscious state (MCS), a condition similar to coma but with intermittent periods of arousal. The patient was chosen for DBS study because while he sustained traumatic cerebral cortex damage six years earlier, his other brain functions were thought to be relatively intact. Electrodes were implanted in the intralaminar nuclei of the central thalamus with the goal to stimulate the undamaged areas of the cortex. Within 2 days of stimulation the patient, who had been in MCS for six years, demonstrated increased arousal. After 2 months of post-op recovery without further stimulation, the patient was subjected to a six month, double blind alternating crossover study to study the effect of DBS on several primary and secondary outcome measures (including motor, communication, arousal, and feeding skills). When stimulated, the patient was able to name objects, make precise hand gestures on request, and chew food. Some functions demonstrated a carryover effect even after DBS was turned off, while other functions required continual stimulation.

DBS has been used experimentally in the past to treat Parkinson’s Disease and other movement disorders, epilepsy, obsessive-compulsive disorder and other psychiatric conditions. Last year, DBS was the subject of a Time Magazine article, How Deep Brain Stimulation Works

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. 

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