Don't Forget the Business Case

John Halamka, the omnipresent CIO for half the health care organizations in Massachusetts, has been every engaged in the problems of sharing data among institutions for some time. In his end-of-the-year summary blog, he distills his 2008 RHIO experience (he's the CEO of MA-SHARE, the Regional Health Information Organization) down to this lesson learned:

Health information exchange for technology's sake is not sustainable. There must be a business value case.

So, as we build RHIOs and shared data systems of all kinds, let's look for solid data that there is a reward to whomever is paying the freight. Likewise, let's make sure that whomever gets the rewards pays to develop and support the system.

Thanks John, and Happy New Year!

The Pitfalls of Computerized Order Entry

CPOE (Computerized Provider Order Entry) is one of the center-pieces of the move to get health care into the digital age. Lots of folks are putting lots of time, money and effort into installing CPOE in hospitals, clinics, nursing homes and everywhere else doctors, nurses and patients interact. There are great expectations for big improvements in quality, costs and work flow.

Years ago, I managed a General Internal Medicine clinic that installed a new Electronic Medical Record and we had some pretty bad outcomes. The amount of work that doctors had to do to get all the data into the EMR was unreasonable. Unfortunately, a few providers tried anyway. They worked long hours, got exhausted and frustrated, and in once case, actually wound up in the hospital as a patient due to the strain of trying to keep up with a badly designed system.

I was hoping that more recent EMRs are more thoughtfully designed, but a recent study by Emily M Campbell, Kenneth P Guappone, Dean F Sittig, Richard H Dykstra and Joan S Ash in The Journal of General Internal Medicine paints a pretty dark picture. They reviewed the experience of five different hospitals that installed CPOE systems and collected a long list of the ways that the systems made things worse, not better, for the users and their patients. Problems included:

• Inadequate desk space to accommodate charts near the computers
• Long sequences of mouse clicks needed to do simple tasks
• Order sets that force the users to change the way they work
• Problems integrating clinical data and orders
• Systems that force the nurses to give medications at specified times rather than the best time for the patient
• Systems that force users to re-enter the orders when the patient is moved to another unit, even when this is not clinically necessary
• Multiple providers entering conflicting orders simoultaneously
• Decision support alerts that don't know enough about the clinical situation to give good advice, but can't be avoided

and many others.

All of these problems have been recognized for a long time. It is disturbing that they continue to appear in the most recent implementations of the systems. At least thoughtful observers like Campbell et al. are providing advice on how to do it better. Can our vendors and institutions learn from them?

Decision Support at Marshfield Clinic

The New York Times published a glowing review today (available here) of the Marshfield Clinic's use of its Electronic Medical Record (EMR) and registry to improve chronic disease care. It also discusses the integration of the EMR into clinical research and other health functions.

You don't actually need a full-service EMR to do all the things they describe. Fletcher Allen Health Care in Burlington, Vermont has been slowly moving towards electronic systems for some time. The Primary Care providers in their eight clinics get reminders to do vaccinations, screening and other health maintenance maneuvers using a home made system that culls the information from the billing data base.

Diabetes care at Fletcher Allen is supported by the Vermedx® Diabetes Information System, which works with or without an EMR.

So, you can achieve much of what Marshfield has without such extensive infrastructure. You don't really need a full-service EMR - but it sure helps!

Decision Suuport and Drug Choice

A recent article in the Archives of Internal Medicine by Michael A. Fischer, Christine Vogeli, Margaret Stedman, Timothy Ferris, M. Alan Brookhart and Joel S. Weissman (all at either the Brigham or Mass General Hospitals in Boston) looked at the effect of simple clinical decision support on prescribing habits. The intervention was simply providing the prescriber with information about the patient's medication insurance coverage at the time of prescribing. After the formulary decision support was turned on, low cost prescriptions (generics or "Tier 1" drugs) went up 3.3%. This resulted in an estimated savings of $8.45 per patient per year! The remarkable and optimistic finding is that they saw these savings with only 12% of the prescriptions getting the decision support.

Caveats - this was not a randomized trial, so it is hard to be sure that the savings were not due to some other factor. Also, the costs of the decision support system may not have been included in the savings calculation.

Nonetheless, this report suggests that even systems that are not very sophisticated (this one doesn't seem to have any clinical acumen - it just looks up the formulary) can have a beneficial effect.

Joint Commission Issues Safety Alert on Health Information Technology

Last week, The Joint Commission, the major regulator and standards-setter for hospitals and other health care providers, issued a "Sentinel Event Alert" on Safely implementing health information and converging technologies. Although the Commission has issued technology alerts before, this one is remarkable in how broad it is, covering the entire domain of HIT and the devices that are attached to the HIT system, including Clinical Decision Support systems.

In it, they noted that 25% of the medication error reports submitted to the US Pharmacopeia involved some kind of computer technology. (It is not clear if this is higher than expected given the prevalence of computerized medication systems in hospitals. Nonetheless, it is a big number.) They also provided a high-level list of 13 suggested actions for implementation and use of HIT that represent a kind of best practices. This list ought to be brought to the attention of everyone involved in these systems - especially the institutional leadership who need to find the funds for these 13 safety steps.

The good news is that Clinical Decision Support was not singled out as a particularly dangerous aspect of HIT (pharmacy took the brunt of the data-driven bad news). Nonetheless, all of us developing Decision Support Systems should keep these issues top-of-mind.

The Right Decisions at the Right Time Saves Lives

(Thanks to guest writer Sarah Scrafford for this post. - Ben)

Medicine and medical treatments have improved and advanced by leaps and bounds over the last 50 years or so, and we have cures for almost all diseases known to man. Of course, newer ones are emerging from the woodwork and researchers and scientists are working tirelessly to mitigate the suffering and extend the lives of people with terminal diseases like cancer and AIDS. But no matter how many cures are discovered, no matter how innovative medical technology becomes, there’s always one aspect that leaves the result of any test or treatment in doubt – the decision of the patient.

There was a time when doctors didn’t involve patients in the decision-making process at all – they just informed them that they needed so-and-so procedure done and that it would cost such-and-such amount. Only the most educated and mature of patients and/or their family asked questions and sought second opinions before going with what their doctor thought. Today though, the scenario is changing; with medical mistakes being made and malpractice suits more in vogue, patients are taking a more active role in their treatment.

Family doctors help a great deal in the decision-making process; when people need surgeries or further treatment for a disease or illness, they are the ones who tell them of the options open to them and ask them to see the concerned specialists. Decision-making involves a series of questions that the patient and his/her family must ask themselves and their doctors. If it involves a surgical procedure or further treatment, the questions normally asked are:

· Should it be done?

· When must I do it?

· Do I stand to lose if I choose not to do it immediately?

· What are my options if I choose not to do it?

· How much will it cost me?

· Is it covered by my insurance policy?

· Who is the best doctor (or which is the best hospital) to handle this procedure?

· How soon can I expect to recover?

· How soon can I expect to get back to work?

· Do I have to undergo physiotherapy after the procedure?

· What are the dos and don’ts to be followed before and after the procedure?

The questions may vary depending on the particular patient and the procedure involved. Some decisions are more difficult than others – like the legal ending of a life in the case of terminal diseases. Washington and Oregon are the only states that allow physician assisted suicide in the USA, and when you’re a terminally ill patient and have the option to take your own life rather than face the suffering ahead which will eventually lead to death, it’s not that easy to choose. On the one hand, there’s the fact that you want to end it all; on the other, you really don’t want to die.

Decisions are difficult, more so when they’re related to your body and may be the difference between life and death, health and illness. So take them wisely, without letting emotions rule you.

(This article is contributed by Sarah Scrafford, who regularly writes on the topic of Radiology Technician Schools. She invites your questions, comments and freelancing job inquiries at her email address: sarah.scrafford25@gmail.com. Thanks, Sarah!)