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