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!)

IT Heavyweights Place Big Bets on Medical Informatics

Both Google and Microsoft are investing heavily in PHRs. The companies had senior-level managers at the Health Care IT Summit in San Diego, Nov. 2008. The event was engineered by The Everything Channel.

Grad Conn is Microsoft’s Senior Director of Global Consumer Health Strategy in the Health Solutions Group.

Alfred Spector’s Google title is Vice President of Research and Special Initiatives. PHRs are one of those special initiatives, apparently.

The two IT giants approach PHRs differently.

Microsoft launched HealthVault in October 2007. It’s a PHR platform designed to store and access personal health and fitness information. It combines single HealthVault records—the storage piece (with access provided by Windows Live ID) —with Live Search Health, a search engine that allows HealthVault users to search for health and fitness information. HealthVault accomodates both the CCR and CCD standards, the latter of which was approved in 2007, and whose proponents say essentially harmonize with HL7s CDAs with CCRs.

Google Health is a PHR in which users voluntarily enter their health records and create one, centralized profile. Even though Google maintains it will not sell advertisin in Google Health, privacy concerns have dogged the concept since it was unveiled in May this year. Google is partnered with Walgreens, CVS, Quest Diagnostics (also a Vermedx® partner), Beth Israel Deaconess Medical Center, and other entities.

Its application programming interface is based on the CCR—an XML-based standard for health records developed to allow physicians to create and transfer electronic health records with ease. “We have no intention of [involving advertising] at this juncture,” said Google’s Spector. (The emphasis is mine.)

Spector explained that one of Google’s key motivations is “. . . the epidemiological research value in the data. It must somehow be valuable over the long term, where we knew drug ‘x’ affected person ‘y’ because of a certain set of factors, and that [a person] could check for not just correlation but cause and effect. Down the road I think that’d be an incredible contribution to the world.”

In contrast, HealthVault is a software and services platform. Conn explained that "like PayPal, we’re an intermediary." Microsoft’s Ballmer has been quoted as saying that health care is one of the top six bets the company is making.

The personal nature of health records, the understanding required to interpret them correctly, and the obvious need for security and privacy have been highhurdles for designers of health data systems. But it appears the design phase is nearly complete, and roll-out is beginning.

The Financial Crisis

Well, this is quite a bit off-topic, but I can't resist posting a link to this lovely slideshow by Chris Hulls on The Financial Crisis: an Historical Perspective. In just 32 beautifully crafted images, he provides a penetrating analysis of how the world's finances fell apart so suddenly. Highly recommended.

Medicare and Personal Health Records

Personal Health Records (PHRs), patient-managed repositories or health information, got a big boost this month when the feds announced that they will share Medicare claims data with 4 vendors. Patients using Google Health, HealthTrio, NoMoreClipboard.com, and PassportM will be able to link their on-line accounts to their Medicare claims data showing many of the health services they use (doctor visits, hospitals stays, outpatient tests, etc.).

This is a big boost to the Health 2.0 concept and represents an endorsement of the idea that patient empowerment is good.

Writing letters to patients

Writing letters to patients is a key part of my clinical practice. Henry Tufo, the mastermind behind the innovative Given Comprehensive Care Clinics at the University of Vermont, made sharing medical records with patients a standard practice years ago. Activating the patient for self-management is the goal and my patients still love getting a copy of their clinical notes, including any recommendations we discussed. What happens when we provide more information to the patient?

An article in this month's American Journal of Managed Care expands our knowledge of the effect of clinical decision support when it is extended to patients as well as providers. A team from ActiveHealth Management in New York City (part of the insurance giant Aetna), evaluated a system which sends decision support messages based on lab and billing data. The alerts to the physicians are followed 10 days later by a letter in lay language to the patient. Using an observational (non-randomized) design and claims data, they evaluated how often the alerts generated the intended action (changing a medication, ordering a test, etc.).

Overall compliance with the alerts was only middling (~30%), but the rates went up when they started sending the letters to patients. The absolute gain of 3% was a statistically significant 12.5% relative gain when adjusted for age, sex, and the mix of alertable issues. In other words, they needed to mail about 33 letters to patients to generate one additional clinical action.

How could the system be improved? The article didn't say how good the data were that the alerts were based on. Billing data are notorious slow to arrive and full of errors. Basing alerts on near real-time information from laboratories and clinical records would help.

Activating the patient sooner rather than later might improve things, too. The Vermedx Diabetes Information System mails the patient letter the same day that it sends out the alert to the provider. This gives the provider only a few days of "grace" and encourages them to develop fast and effective office systems (so they get fewer alerts in the first place and deal with them before the patient calls).

Although the authors did not present any financial analysis, my back-of-the-envelope calculations are promising: If a letter costs $1.50 to generate and mail, the cost of moving one patient to a better state of care would be about $50. This is likely a very good bargain for many conditions. What's missing, though, is convincing evidence that the system really improves outcomes and saves money. For that, we will need a large scale randomized trial.

Diabetes Incidence Going Up

The CDC just released more data on the incidence of diabetes by state. The rates have almost doubled over the last 10 years and now stand at about 9 new cases per 1,000 persons (age adjusted). That means 1.3 million new diabetic patients every year!

Minnesota has the lowest rate of new cases at 5/1000; Puerto Rico topped the list at 12.8.


We're going to need much better systems of chronic care management to handle the influx of millions of new patients. Or else, we can expect millions of premature heart attacks, strokes, kidney failures, amputations, and deaths. The costs will be overwhelming unless we get these patients insured, deploy smart management techniques, and pay very close attention to them over the years.