More communication = better blood sugar in Type 2 diabetes

150 veterans with type 2 diabetes in Pittsburgh were part of a randomized trial recently reported in Diabetes Care in which half of them got basic disease management (monthly calls from a nurse practitioner) and half got that PLUS home telemonitoring of blood glucose, blood pressure and weight. All the patients improved over 6 months, but the exchange of information between the patient and the provider resulted in a bigger drop - over 1% more of HbA1C. That's more than you usually get from adding a second or third medication.

Once again, the more the communication between the patient and the provider, the better the outcomes. Hats off to Drs. Stone, DeRubertis and company!  Now, the trick is to find the most efficient and effective way to do it.

Using Health Information to Find Bad Medicines Quicker and Cheaper

Here is a very valuable use of personal health information aggregated to a population level. John Brownstein and colleagues from Harvard used a network of electronic medical records systems to gather up over 34,000 patient records and confirm that the diabetes medication rosiglitazone (sold as Avandia among other trade names) is associated with an increased risk of heart attacks. Of course, that's not really news. What is even better is that they showed that if they had been doing this back when the drug was introduced (1999), they would have found the association in late 2000, rather than 2007, when the reports first appeared.  

Rapid identification of myocardial infarction risk associated with diabetic medications using electronic medical records by Brownstein, J. S., Murphy, S. N., Goldfine, A. B., Grant, R. W., Sordo, M., Gainer, V., Colecchi, J. A., Dubey, A., Nathan, D. M., Glaser, J. P., Kohane, I. S. Diabetes Care Journal publish ahead of print articles

Finding out years earlier that a commonly used drug has an important adverse effect is a very good thing and ought to be a big part of the business case for more exchange of information.

Contractual gag orders in EMRs - a petition

MedInformaticsMD and the good folks at Health Care Renewal  have launched an interesting and important electronic petition drive about Transparency and Openness in Electronic Patient Records and Other Healthcare Information Technology Systems. The key issue is that some manufacturers of electronic medical record systems and related technology put clauses in their service contracts that customers may not publically report or discuss bugs or problems in the system. Even truly disastrous problems that result in patient deaths or institutional mayhem are subject to these gag orders, limiting the ability of the medical and health IT communities to mitigate, repair or avoid them.


I share the belief that these kinds of restrictions are bad for patients, bad for providers, bad for the country, and in the long run, bad for the manufacturers themselves. So, I have signed the petition online, and suggest that you consider doing so, too.

Vermedx highlighted in VermontBiz.com

We're so proud! VermontBiz .com interviewed our own Charlie MacLean and did a great profile on Vermedx, so check it out!

Diabetes Registries for Public Health Surveillance

We missed it back in 2008, when it first came out, but this article from Washington state is worth going back for. The good people in the state health department linked together a bunch of clinic-based diabetes registries to get a bird's eye view of the quality of diabetes care across the state. This is an approach we used before in New York City, San Antonio and Vermont and we're glad to see it being used in the Evergreen State.

The difficulty with the clinical registry product that they used is its heavy reliance on manual data entry. To cover a broader segment of the target population at much lower cost, we use automatic data feeds from clinical laboratories. But, the idea is the same and its a good one - exchange clinical information with public agencies to improve their ability to manage the health of the state's population.

Exploring the feasibility of combining chronic disease patient registry data to monitor the status of diabetes care.

Prev Chronic Dis. 2008 Oct;5(4):A124. Epub 2008 Sep 15.

Kemple AM, Hartwick N, Sitaker MH, Harmon JJ, Clark K, Norman J.

Chronic Disease Prevention Unit, Washington State Department of Health, PO Box 47855, Olympia, WA 98504-7855, USA. angela.kemple@doh.wa.gov

INTRODUCTION: To provide direction and to support improvements in diabetes care, states must be able to measure the effectiveness of interventions and gain feedback on progress. We wanted to know if data from multiple health clinics that are implementing quality improvement strategies could be combined to provide useful measurements of diabetes care processes and control of intermediate outcomes. METHODS: We combined and analyzed electronic patient health data from clinic sites across Washington State that used the Chronic Disease Electronic Management System (CDEMS) registry. The data were used to determine whether national and state objectives for diabetes care were met. We calculated the percentage of patients that met standards of care in 2004. RESULTS: The pooled dataset included 17,349 adult patients with diabetes from 90 clinics. More than half of patients were above recommended target levels for hemoglobin A1c testing, foot examination, hemoglobin A1c control, and low-density lipoprotein cholesterol control. Fewer patients met recommendations for nephropathy assessment, eye examinations, and blood pressure control. In terms of meeting these standards, rates of diabetes care varied across clinics. CDEMS rates of care were compared with those reported by other data sources, but no consistent pattern of similarities or differences emerged. CONCLUSION: With committed staff time, provider support, and resources, data from clinical information systems like CDEMS can be combined to address a deficiency in state-level diabetes surveillance and evaluation systems--specifically, the inability to capture clinical biometric values to measure intermediate health outcomes. These data can complement other surveillance and evaluation data sources to help provide a better picture of diabetes care in a state.

Tweeting for Health

Recently, we've posted about collecting data from patients via brief text messages (SMS) over their cell phones. Today, we have communication in the opposite direction: sending prompts to patients to encourage certain behavior.

Text-Message Reminders to Improve Sunscreen Use: A Randomized, Controlled Trial Using Electronic Monitoring
April W. Armstrong, MD; Alice J. Watson, MD, MPH; Maryanne Makredes, MD; Jason E. Frangos, MD; Alexandra B. Kimball, MD, MPH; Joseph C. Kvedar, MD
Arch Dermatol. 2009;145(11):1230-1236.

This group sent the local weather report along with a reminder to wear sunscreen to 35 adults via their cell phones. After 6 weeks, sunscreen usage was 56% vs 30% among 35 control subjects (P<.001). The NNT (Number-Needed-to-Text) was a very low 3.8, suggesting that about 1 in 4 subjects responded to the messages. This is remarkably high success rate for such a low cost intervention and suggests that text messages might have broader applicability in health behavior change.

What other areas would benefit from a periodic cell phone reminder?  Where won't it work?

Position available - Director of National Sales - Vermedx, Inc.

Director of National Sales
Vermedx®, an exciting chronic disease decision support solutions company, is looking for a Director of National Sales to sell decision support technology to providers, payers, employers, and health plans. This individual will be responsible for all aspects of managing and closing a complex strategic sales process including pipeline maintenance, territory analysis, initiating and maintaining client relationships, client needs and readiness analysis, sales presentations, proposal preparation, and maintaining up-to-date knowledge of competitors. The Director will be accountable and rewarded for generating revenue growth.
Duties include:
• Develop sales strategies
• Create and maintain target prospect list
• Coordinate regional sales events
• Qualify prospects
• Deliver sales presentations
• Forecast and report sales activity in Salesforce.com
• Prepare written sales materials and proposals
• National travel
• Communicate via e-mail and electronic shared work platforms
• Partner with team resources, including the executive staff, as needed to win and maintain business
Qualifications
• At least 7 years of experience selling to IPAs, Payers, and Health Plans
• A track record of success selling healthcare software and technology
• Significant experience interfacing at the C-Level
• A strong understanding of business operations in the healthcare space
• Ability to partner with key technology partners
• Ability to prioritize opportunities, and manage time independently
• Established relationships with executives and IT decision-makers throughout the healthcare community
• Proven success in maintaining relationships within the healthcare community

The Director reports to the CEO and will enjoy a generous base salary plus commissions and the opportunity to participate in equity growth. Although Vermedx corporate offices are in beautiful Burlington, Vermont, the Director may reside anywhere in the country. To apply, please write to Benjamin Littenberg, MD, CEO, Vermedx, Inc. (ben@vermedx.com). Please include a resume and references.
www.Vermedx.com

Yet more on Open Mobile Health Exchange

Karen Edwards-Crawford said:

Better access to patient's medical records would be a great improvement. There are times when I can't even get records from a facility that is only five mile away. What's up with that?

So many reasons why we can't routinely share data in the interests of the patient: legal, social, political, economic. Sometimes, just a failure of imagination! However, the technical barriers are mostly solved or nearly so. The real challenge is developing a social consensus that this is something we ought to do and agreement on how we should all behave so that patients (and their data) don't get abused. We've made great strides with sharing laboratory results for diabetes among providers (and the patient - a key ingredient!), but uptake by the healthcare industry is slow. Many of the key decision makers, especially on the insurance side, are wary. They are more worried about losing their franchise in the future altogether than improving quality and reducing costs now. They also want a "one-size-fits-all" solution that will solve all their operational issues at once. And, they believe their competitive advantage lies in cost-center control rather than quality improvement. So, they are holding out for a mandated solution that their competitors must do at the same time they do, that fixes all the ills of the health care system (not just one or two conditions, no matter how important), and that someone else will pay for. The net result is that they're leaving hundreds of millions of dollars on the table, doctors like Karen Edwards-Crawford are frustrated, patients get care they don't need and don't like, costs go up for everyone, and the government mandates more and more controls.

There is some good news. Some small insurers and provider groups around the country (like FirstCare in Texas) have figured out that they can see big benefits in the short run (this fiscal year) by making small targeted investments in intelligent, proven health information exchange programs for critical areas like diabetes. These payers and providers are positioning themselves to thrive no matter what comes out of reform legislation and no matter how long it takes to get the bugs out of massive comprehensive medial records programs. So, it feels like two steps back for every one step forward, but maybe we are inching towards a better place! It certainly has kept things interesting for solutions providers like Vermedx.

More on Open Mobile Health Exchange

Michael Henry wrote:

Given the current state of technology, one would think we would each be wearing a thumb drive on a lanyard around our neck that any medic could access almost instantly. I suppose privacy concerns are the greatest factor precluding that.

Good point. Actually, we're getting a bit closer with a document standard called a CCD which defines the structure for what might be in the thumb drive. Privacy is probably no longer the limiting factor. Making sure the data on the drive (or more likely, the web repository) is up to date is a bigger issue.

Open Mobile Health Exchange

Getting information about specific patients' current situation is one of the biggest problems in clinical decision support. Perhaps what's needed is a simple short messaging protocol that allows Twitter-like text strings to be both machine- and human-readable. I wish I thought of it, but the good folks at microsyntax.org get the kudos.

OMHE (Open Mobile Health Exchange), pronounced "ooommm," is an open-source microsyntax for text messaging (mobile SMS), Twitter®, medical devices, and other "short text capable" systems.

OMHE has a short list of standard messages and commands like

wt=182

to transmit a current weight or

getphr

to request a copy of your personal health record. The target audience includes cell phone users entering personal info on the go, distributed data collection devices like blood glucose monitors and pedometers, and patient services like personal health records or disease management nurses. I think this idea may have real utility in a variety of settings, and being open-source is a big plus.

More can be found at http://code.google.com/p/omhe/

AMIA Year in Review

This just in - your blogger is bursting with pride as the American Medical Informatics Association released the AMIA Informatics 2009 Year in Review: A compendium of notable publications and events in the field of biomedical informatics. There we are, second in the list of studies about decision support for patients: Littenberg B et. al. The Vermedx Diabetes Information System reduces healthcare utilization. Am J Manag Care. 2009 Mar;15(3):166-70.

Professor Masys of Vanderbilt, who compiles the list, puts a heavy weight on randomized controlled trials in picking the entries, as well he should. Thanks for including us!

Diabetes Quality of Care

AHRQ (the US Agency for Healthcare Research and Quality) recently published an analysis of the quality of diabetes care across the country. The numbers are (still) not good. 7.4% of Americans (16.5 million people) have been told they have diabetes. (Probably another 8 million don't even know it.) Among seniors, the rate goes up to 18.3%.

Only a third of diabetic patients have had the 3 basic tests (an A1C test, an eye exam, and a foot exam) in the last year. The AHRQ didn't even report on cholesterol, kidney function, urine tests or the fact that good care requires 2 to 4 A1C tests per year - not just one.

So, we're still not applying the good science we have about diabetes to the benefit of Americans with the disease. Why not? Lots of reasons including access to care (read health insurance), patient factors (language or cultural barriers, fear, ignorance, illegal residence, etc.), conflicts with other health and personal needs (work, family, etc.), and poor systems of care. We still don't use the tools we have (computers, checklists, flowsheets, reminders and the rest) to ensure that basic needs get met with regularity.

There is hope as more and more people realize the tremendous waste of lives and money associated with sloppy care. The solutions are fast, cheap and easy, but they do require thinking about systems of care, not just visits, and about small investments that yield big savings.

The full report is available for free: Soni, A. Diabetes Management: Tests and Treatments among the Adult U.S. Civilian Noninstitutionalized Population, 2007. Statistical Brief #269. November 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st269/stat269.shtml

The National Association of Managed Care Physicians

The National Association of Managed Care Physicians (NAMCP) will be hosting the annual Fall Managed Care Forum in Las Vegas this week. I'm honored and excited to be on the program on Thursday, November 12 at 1:30 at the Bellagio. I'll be talking about "Treatment Improvement and Cost Savings in Diabetes Care" and how the Vermedx Diabetes Information System improves the quality of care for patients and providers while saving the payer over $2,400 per year.

You can learn more about the meeting at www.namcp.org.

See you in Vegas, baby! 

Vermedx Video

Here is a video presentation about the Vermedx Diabetes Information System and the savings it generates for payers, providers and patients.

Vermedx and Texas

FirstCare Texas has signed a contract with Vermedx, Inc. to provide its patent-pending Vermedx Diabetes Information System (VDIS) for the use of health care providers and patients belonging to First Care Health Plan's health maintenance organization operating in Lubbock, Waco, Abilene, and Amarillo, Texas.

FirstCare CEO Clifford Frank cites the success of the Vermedx Diabetes Information System, as detailed in the March 9 edition of The American Journal of Managed Care. This article describes how Vermedx reduces annual treatment costs by an average of $2,400 per adult patient while improving patient treatment quality. "It's a very cost-effective, quick to implement and easy to operate technology for our providers to add to their repertoire of tools for improving patient satisfaction and enhancing treatment quality," said Frank.

VDIS captures laboratory test results from multiple labs and provides patient-level evidence-based best practices recommendations for care. VDIS also provides quarterly population reports that help clinicians focus on highest risk and out-of-compliance patients in addition to generating automated reminder and alert letters for patients. VDIS is currently being utilized by primary care physicians in managed care and integrated hospital systems in three states, following a successful five-year NIH sponsored clinical trial.

FirstCare is owned by two religious-based health systems -- Covenant Health Systems in Lubbock, Texas, and Hendrick Health Systems in Abilene, Texas. FirstCare has been serving the health insurance needs of approximately 200,000 members since 1986. The corporate headquarters are located in Austin, Texas, with satellite offices in Abilene, Amarillo, Lubbock and Waco.

Errors in Google Health

Google Health, the Personal Health Record (PHR), has quite a nasty problem. The Boston Globe reported that at least one patient had major errors in his record. The errors were quickly traced to Google's use of billing codes to drive its diagnosis and problem lists.

The good news is that Google 'fessed up and says it has learned from the episode. The bad news is that they may not have learned very well. Neil Versel reports that Google managers now say that "...Google Health would now allow free-text diagnoses that didn’t have to correspond to a billing code."

The underlying problem is not just that billing codes may be inaccurate, but that all data may be inaccurate, out-of-date, or misleading. Free text is notoriously difficult to work with and certainly prone to its own problems and errors. The problem of automatically constructing a patient profile from warehoused data is analogous to the problem of diagnosing a patient complaint. Very rarely does any one bit of data from history, physical exam, laboratory or imaging unambiguously make the diagnosis. Conflicting possibilities need to be resolved by assembling a (sometimes large) list of data points and finding the underlying pattern that explains them.

Likewise, the role for PHRs is not just to assemble the data about a patient. Making a diagnosis from those data requires very sophisticated algorithms that take into account the inherent quality of each data point, the process that produced it, how it relates to other data, when and where it was collected, and so forth. When you are all done, even the best systems are still going to have both false-positives (listing something not really true, like what happened to Dave deBronkart on Google) and false-negatives (missing something important).

How do we handle this on the Vermedx Diabetes Information System? The system provides very actionable advice to both providers and patients, so we need it to be very, very accurate and reliable. Before we do any contact with the patient, we do something a bit like what Google and other PHRs do: we automatically scour computerized records. In our case, the data are primarily clinical laboratory results which are generally much more reliable than billing codes. Then, we check with the primary care provider and ask them two critical questions: Is this patient truly diabetic? Are they really your patient? Only when we have two "yes" answers do we even offer to enroll the patient.

Even with this level of feedback and control, we still have false positive results. So, when we do contact the patient, we ask them to tell us if the information is incorrect. Some patients have moved, switched doctors or even died without the primary care practice knowing. And, sometimes the provider told us "yes" when they should have said "no."

The point is, we don't trust just data source. Even in this seemingly simple domain of a single diagnosis with good laboratory tests that are reliably reported, we need to combine multiple data sources to achieve high quality information. PHRs need to do more than copy a list of apparent diagnoses from one database to another. They need to explain the data's provenance, strengths and weaknesses, and help the user decide whether to accept, reject, or modify the tentative conclusions reached by the system. This is not easy, but when you do it well, there are big pay-offs!

How much is an e-mail worth?

According to the Santa Cruz Sentinel, doctors in Palo Alto, California are offering a new service to their patients: e-mail with their doctors. The fee is $5 per month. The e-mail option is apparently too new to tell how patients feel about it.

I've been exchanging e-mails with my patients for over 15 years, although I've never charged for it. It is much easier than playing phone tag and cheaper for the practice than involving a secretary and a nurse in message handling. (The toughest part right now is attaching the patient's birth date or record number to the message and getting it filed in our (still paper-based) record system. A dedicated secure e-mail portal could take care of that easily.) The volumes have never been very large and I have no fear of being overwhelmed.

How does it effect income? In my experience it almost never replaces a visit. Rather, it substitutes for one or more phone calls. And, like phone calls, it sometimes ends in "You had better be seen."

I'm not tempted to charge for the service, but it does seem like a smart thing to include in a capitation fee or medical home charge. Many insurance companies encourage patients to call or e-mail a health plan nurse for general advice. It seems logical that they should support the patients contacting someone who can give them even better advice: their doctor!

Health Technology News

Thanks to Rich Elmore at Heath Technology News for his recent coverage of Vermedx® and the recent studies showing its impact.

Rich does a great job covering both the business and health sides of HIT and his column is a must-read, always.

Cost savings from Vermedx® decision support

The American Journal of Managed Care has their web site back up, so here is the link to our new article:

The Vermedx® Diabetes Information System Reduces Healthcare Utilization
Benjamin Littenberg, MD; Charles D. MacLean, MDCM; Karl Zygarowski, BS; Barbara H. Drapola, RN; James A. Duncan, MD; and Clifford R. Frank, MHSA
Am J Manag Care. 2009;15(3):166-170
Published Online: March 16, 2009 - 12:00:07 AM (CDT)

It shows that the savings estimated in the NIH clinical trial of Vermedx® are confirmed in an analysis of managed care claims paid. I posted the abstract and a key figure Sunday. Here is the table showing the savings that are generated when patients are enrolled in the Vermedx® Diabetes Information System.

Table 2: Net savings per patient as a function of duration of the VDIS program

Duration (months)	Monthly savings	Annual Savings	Cumulative savings
12	$80.96	$504.24	$504.24
24	$165.92	$1,523.76	$2,028.00
36	$250.88	$2,543.28	$4,571.28
48	$335.84	$3,562.80	$8,134.08

Savings are calculated net of the costs of the program.

For more information, please see www.Vermedx.com.

The Vermedx® Diabetes Information System Reduces Healthcare Utilization

The American Journal of Managed Care published our article last week. Unfortunately, their web site got hacked and the PDF is not yet available. However, here is the abstract and main figure to tide you over till the whole opus is downloadable.

The Vermedx® Diabetes Information System Reduces Healthcare Utilization
Benjamin Littenberg, MD; Charles D. MacLean, MDCM; Karl Zygarowski, BS; Barbara H. Drapola, RN, CCM, CPHQ; James A. Duncan, MD; and Clifford R. Frank, MHSA
Am J Manag Care March 2009;15(3)
Objective: To confirm the cost savings in a randomized clinical trial of the Vermedx Diabetes Information System (hereafter referred to as the Diabetes Information System [DIS]) in independently collected data using claims paid by a managed care insurer for patients with and without DIS participation.
Study Design: Longitudinal analysis of paid claims with concurrent and historical controls from October 2002 through October 2007.
Methods: Using locally weighted smoothing functions and linear regression analysis before and after commencement of the DIS, we compared the total claims paid per member per month for 153 patients using the DIS versus 870 control patients.
Results: For DIS patients, paid claims increased at a rate of $8.30 (95% confidence interval [CI], $1.12-$15.48) per month before the DIS started compared with −$3.92 (95% CI, −$9.50 to $1.67) after commencement of the DIS (P = .008). For control patients, the slope changed from $6.80 (95% CI, $3.78-$9.82) to $3.16 (95% CI, −$1.06 to $7.38) (P = .17). After commencement of the DIS, the slope of the claims in the DIS group is significantly lower than that of the control group (−$3.92 vs $3.16, P = .046). The mean estimated savings range from $504 per patient in year 1 of operations to $3563 in year 4. The cumulative net savings reach $8134 in 4 years.
Conclusions: Participation in the DIS is associated with substantial reductions in claims paid, net of the costs of the intervention. The cost savings reported in the randomized clinical trial of the DIS are reproduced in an independent data set.

Figure 1: Claims paid per member per month estimated by non-parametric locally weighted smoothing. The vertical line represents the start date for VDIS patients and a randomly chosen date for control patients.

IBM's "Google Earth for the Body"

IBM has a new interface idea for the medical record: a humanoid avatar. It's a 3D image of a human body, with the patient's data linked to the various body parts. Users click on the heart to get cardiac reports, the kidney to see renal information, etc. They tried it out in a Danish hospital and report good results.

On the face of it (actually, the pictures I saw had no face), its a really cool technology, bit its hard to see what problem its solving. Do doctors and nurses need that level of help organizing information? In my experience, anatomic thinking is not where we fall down. How can this technology help us see the systems and connections among the organs? The out-of-body factors (environment and interpersonal relationships) and microscopic forces (genes and proteins) that drive so much of health don't have an obvious place in this model.

One potential upside: it could be a great way to educate patients about their health.

What do you think about using this technology to improve care?

ePrescribing Increases Errors

A recent report in the open-access journal BMC Biomedical Informatics and Decision Making describes the experience of 3 large pharmacies in Sweeden. They found, as have others, that a sizable fraction of prescriptions need clarification before they can be dispensed. "Clarification" means the pharmacist cannot safely and reliably fill the order without contacting the prescriber. This is a good practical definition of "error" in this setting. These errors represent re-work for the prescriber, delay in care for the patient, and increased costs to the system. Some of them also represent potentially dangerous actions that put the patient at risk for illness, injury or death.

One of the main reasons to change from hand-written prescriptions to ePrescribing is to reduce the need for clarifications and the errors they represent. Unfortunately, the Sweedish team found that ePrescriptions were substantially more likely to need clarification than the old-fashioned ones. 2.0% for the electronic scripts vs. 1.2% for the older type.

Many of the errors could be traced to lack of standardization across ePrescribing systems. The authors also called for more training of users. However, anytime a system requires extensive training, that means it has too many inherent failure modes. For ePrescribing to truly save lives and money, the interfaces to the users need to be intuitive, easy-to-use, and supportive of the user's tasks. Until then, ePrescribing, like Computerized-Provider-Order-Entry, will just be another failure mode.

Confidentiality concerns may delay health IT investment

According to Robert Pear in today's New York Times, a wrangle over the confidentiality of health information could delay a $20 billion federal investment in Health IT. Some of the proposals seem pretty smart, like outlawing the sale of health records without the patient's permission.

Others strike me as seriously flawed, such as not allowing the routine transfer of electronic health information for care of the patient without specific permission. (Although HIPPA does not require this permission for care, the early proposals did. Even now, many folks still believe that they cannot transfer medical records to the patient's doctor without a specific permission - causing endless delays, confusion, and rework.) If interpreted too strictly, we could be in the position of knowing some information that could improve a patient's health or even save a life, but be constrained from acting on it. Public Health IT, in particular, could be seriously compromised - think tracking infectious diseases, but not being able to tell patients who might have been exposed.

A more difficult proposal is to allow patients to segregate some of their medical records as too embarrassing to allow out even with the confidentiality rules used for general medical information. I can certainly understand that information related to mental health, sexual behavior, paternity and a host of other issues needs to be handled with care. However, I believe that 1) all health care information deserves that level of care and 2) mental health, in particular, has suffered as medicine's step-child due to assumptions that it is somehow "different" or "special." Bringing these issues into the medical fold may be very benficial, as it was for cancer and diabetes, which are no longer "shameful."

The problems of data security and confidentiality that have been widely publicized (leaking health records to the press, for instance) do call for action. However, the best action would be serious enforcement of laws and standards that currently exist, rather than an extensive re-write.

New National Research Council Report on Health IT

The National Research Council just came out with a report on computers and health: Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, that outlines a grand vision of what's wrong with HIT and what to do about it.

Here are their 9 principles to guide the use of HIT:

1. Focus on improvements in care —technology is secondary.
2. Seek incremental gain from incremental effort.
3. Record available data so that today’s biomedical knowledge can be used to interpret the data to drive care, process improvement, and research.
4. Design for human and organizational factors so that social and institutional processes will not pose barriers to appropriately taking advantage of technology.
5. Support the cognitive functions of all caregivers, including health professionals, patients, and their families.
6. Architect information and workflow systems to accommodate disruptive change.
7. Archive data for subsequent re-interpretation, that is, in anticipation of future advances in biomedical knowledge that may change today’s interpretation of data and advances in computer science that may provide new ways of extracting meaningful and useful knowledge from existing data stores.
8. Seek and develop technologies that identify and eliminate ineffective work processes.
9. Seek and develop technologies that clarify the context of data.

This is an important and welcome report by an experienced and wise team led by Bill Stead of Vanderbilt. The emphasis on achieving clinical results rather than achieving technology is, of course, an old lesson. But it warrants repeating. It is better to install a small system that you know will make one thing better than a giant system that you hope will make everything better. Such small systems need to be designed with integration in mind. But, if the system demands a wholesale change in behavior or a radical investment of financial, intellectual and human capital, watch out!

Happily, there are some approaches already available that meet the 9 principles. The Vermedx® Diabetes Information System meets all of them. It does it by having a narrow scope (just laboratory management for adults with diabetes in primary care). And, I would add another principle that Vermedx meets:

10. Demand rigorous evaluation

Morris F. Collen, M.D.

Congratulations to Morris F. Cullen, the pioneering physician informatacist at Kaiser Oakland. Dr. Cullen is writing his sixth book: "The History of Medical Informatics: The Clinical Support Systems." I, for one, am looking forward to it!

Maria L. La Ganga of the LA Times wrote a glowing profile of the nonagenarian physician with lots of great tid-bits. My favorite: his driver's license expires on his birth date on "11-12-13." Y2K lives!