Is the Revolution Upon Us?

Amar Gupta, the Thomas R. Brown professor of management and technology at the University of Arizona, writes in the Wall Street Journal that the revolution in IT that transformed banking, manufacturing, media and many other aspects of American business is finally about to descend upon the health care industry. Setting aside that this is the same promise I heard from my medical school graduation speaker in 1979, and that Prof. Gupta doesn't provide a time line, he does provide a nice analysis of three potential modes of health care:

In the future, there will be three often overlapping modes of delivering health-care services: services performed in person by humans, services that can be performed by people at a remote location, and services performed by computers without direct human involvement.

Services at remote locations are a no-brainer and already here: mail order pharmacy, off-shore transcription, tele-radiology, tele-medicine, tele-surgery. Computer-only services are going to be the real revolution. Automating the clinical laboratory made it one of the most reliable aspects of health care. Electrocardiograms that come with their own interpretation have long made cardiac care better everywhere. The Vermedx® Diabetes Information System currently uses IT to replace the failing human reminder and decision making systems in one small aspect of primary care.

Perhaps what's notable about these examples is not the pure processing aspects (although interpreting an electrocardiogram is pretty remarkable), but the connections to the human systems. Figuring out how to send a computer-generated message to a human doctor, nurse, or patient is not easy. It required literally years of tinkering and adjustment to get Vermedx® to work. Although our experience is valuable, there are no rules for how to do this in the next setting.

So, yes, I think the revolution is coming, but maybe not as fast as the Professor suggests.

Twitter for health?

PF Anderson from the University of Michigan recently posted a slideshow that suggests (among a zillion other interesting ideas), that micoblogging with Twitter can be used to do personal health behavior logs. For instance, a patient with diabetes, might send a text message from their phone every time they check their blood sugar.

It's a very interesting idea. I was involved a few years back with Interactive Voice Response Telephony (IVR "Press 1 if you want accounts, press 2 if you....") for depression and asthma. Patients would enter their symptoms, medication adherence, and other pertinent events. The system would summarize the patient's course and periodically send an up date to the patient and the provider. Some patents loved it, some loathed it. John Helzer and Magdalena Naylor at The University of Vermont have had very good results using it for problem drinking and chronic pain.

Can we provide decision support to patients this way? The biggest problem with all health diaries is patient adherence. The good thing is that Twitter might make it easier for some patients to make entries. The bad thing is that incomplete data is sometimes worse than no data at all. Of course, Twitter can "nudge" a user to make an entry, so maybe that will help.

Anybody have any experience with Twitter or other such systems for communication with patients?

Ben

AHRQ Web M&M on Electronic Health Records

Every month, the federal government's Agency for Healthcare Research and Quality (AHRQ) publishes a free on-line journal about patient safety or some other aspect of quality. Edited by Bob Wachter, MD, these articles take the form of a case report with discussion by an expert. (There is also a quiz and free CME for physicians and others.) This month, the spotlight article focuses on the safety impacts possible by linking together medication information and laboratory information across a variety of settings - primary care, Emergency Room, and inpatient hospital. The discussant, Ted Eytan, MD, MS, MPH, argues that an Electronic Health Record could have prevented the repeated medication errors described.

In particular, Dr. Eytan argues that routine discharge summaries are ineffective in getting the right information to the primary care provider at the right time. Although he advocates for full-scale cross-institutional EHR solutions, I feel there is plenty of room for specific focused solutions to the problems of communicating with us primary care physicians. As much as I would love to have a full-service EHR, we can't afford to wait! We need to use the solutions that are on hand now and integrate them into the EHR when it is finally ready.

As always, AHRQ's Web M&M is always well-written, thoughtful, and worth checking out.

Ben

Are EMRs Ready for Primary Care?

I thought I was the only one thinking like this, but I'm happy to see that I'm not so alone. Shahid N. Shah at the The Healthcare IT Guy found this article in HealthcareITNews:

"When you put an EMR into a primary care practice, your life is hell for the next year," said L. Gordon Moore, MD. "EMR vendors aren't really giving us what we need. We have to make a distinction between a robust EMR with decision support tools, and one that is just being marketed as a way to improve coding. And we really need to get out of the E&M coding game."

I couldn't agree more completely with this sentiment. Getting IT support for delivering care rather than just for generating bills is the critical missing link in most EMRs. Even the ones with "decision-support modules" don't really do all that can be done to make life better for physicians (as Moore emphasizes) and (even more important) patients.

Ben

Light Registries: All the taste -- none of the data entry

Recently Healthcare IT News published a story on the positive effects of a diabetes registry on the quality of care at Duke. They report that Duke has used DocSite, a registry product, for about a year and has improvements in the achievement of “perfect care”(in which the patient is on time or on target for every guideline). They report a "doubling" of this rate (although they don't report the rate itself, which is notoriously low - often well below 5%.)

DocSite has been around a long time in various forms and has suffered in the past from a major limitation: somebody has to type in all the data: labs, visits, vitals, smoking status, you-name-it. This limitation has caused many practices to give up on chronic disease registries. However, there are two strategies that can help: one is to use the registry as a back end to an EMR that already has all the interesting data in machine-readable form. I suspect this what Duke is doing. Essentially, the DocSite decision support tools are bolted on to the EMR.

The alternative is to develop a lighter registry that contains only those data that are easily accessible. For instance, Vermedx depends primarily on laboratory data because they are almost always electronic from the moment they are generated. As other data types become available (vaccine usage, medications, vitals, etc.), they can be added to the system with a concomitant expansion of decision support capability. Until then (which still looks like a long way off for most Americans), a registry like Vermedx can provide huge benefits without requiring a tremendous effort in data entry. It can:

• allow population views at various levels (practice, provider, geographic, age-based, etc.)
• drive communications to the practice about exactly what to do next
• drive communications to the patient about what to expect and how to get it
• stimulate improvements in the essential office micro-systems that are at the root of Primary Care quality
• identify patients who need extra attention from specialists, case-managers or other resources
• connect the practice to lab results from outside institutions - even if the two institutions don't share any infrastructure

These advantages, which translate into huge savings for the system as well as improved quality of life for the patient, are how, as Blackford Middleton of the Center for Information Technology Leadership puts it,

“...diabetes registries are the only form of information technology-enabled diabetes management we found to be cost-beneficial when adopted for patients with Type 2 diabetes.”

The challenge now is how to get light registries in use now while everyone is so busy installing (or planning to begin to think about installing) large, complex EMRs. We need the savings and the quality improvement now! This is a case of the perfect being the enemy of the good.

Ben

Health Informatics Discussion Forum

You can't do it alone and the web gives us some great opportunities to get help from the pros around the world! Many thanks to Abbas Shojaee and Dr. Gil (Gunter) Pollanz from Chris Paton's Health Informatics Discussion Forum for the excellent advice and insight they provided on Vermedx. You can see the whole thread here.

If you have ideas on how to make personalized clinical decision support better, faster, cheaper, higher, louder or just plain cool, please join the discussion either here or at the Health Informatics Discussion Forum.

Thanks

Ben