The Internet and Chronic Disease

The good folks at the Pew Research Center have produced another excellent report. This one is on the relationship between access to the Internet and having a chronic disease. No, its not another "The Internet is destroying everything noble" story. Rather, maybe we need even more Internet.

"U.S. adults living with chronic disease are significantly less likely than healthy adults to have access to the internet (62% vs. 81%). The internet access gap creates an online health information gap. However, lack of internet access, not lack of interest in the topic, is the primary reason for the difference. Once online, having a chronic disease increases the probability that someone will take advantage of social media to share what they know and learn from their peers."

Why is this? One reason (suggested by John Robitscher of the the National Association of Chronic Disease Directors) is that chronic diseases are more likely in poor people who also have a lower liklihood of Internet access. However, even if poverty is a confounder, the benfits of access to health information may be least likely to go where they are needed the most.

See the full report from Pew here.

Exchanging Data in Other Settings

It's not personal health data, but here is a very interesting take on the power of sharing information by Tim Berners-Lee, the wizard behind the Internet: http://www.ted.com/talks/tim_berners_lee_the_year_open_data_went_worldwide.html

The use of Open Source Wiki Mapping to help rescue workers in Haiti is brilliant!  How can we use this approach in Health Care?

Do Computetized Decision Support Systems Work?

How should decision support be delivered to doctors and other providers? Very simple supports, like "don't forget to do a mammogram in this 55 year-old woman," or "CT scans of the brain aren't very useful in patients without specific findings on neurologic exam" can be delivered a variety of ways - on paper or via order entry systems, or even as standing orders that require no provider input. 

But lots of medical problems are more complex. Managing chronic disease or polypharmacy or multiple diagnoses calls for multidimensional reasoning and is a notoriously difficult task for humans to master. It seems like a great opportunity for computerized decision support. One vision is that the provider interacts in real time with a computer screen that solicits inputs, provide advice, and encourages best practices. This kind of support is one of the big arguments in favor of electronic medical records. But, does it work?

This week, a new systematic review was published that examined the effectiveness of such multidimensional, real-time decision support systems in outpatient care. The results are not heartening. The authors reviewed 27 comparative studies. Less than half showed some benefits in terms of improved process measures (documentation, adherence to recommendations, etc.), but there was very little evidence that patient outcomes improved.

They conclude that

"There is little evidence at the moment for the effectiveness of an increasingly used and
commercialised instrument such as electronic multidimensional guidelines."

Why didn't they work?  It's not entirely clear, but possible reasons include bad interface design, poor integration into work flow, overwhelming volumes of feedback, hardware failures, and tedious data entry requirements. Of note, these systems generally did not involve the patient in the decision support interaction, which may be key to getting improved outcomes.


You can see all the details here:
Effectiveness of electronic guideline-based implementation systems in ambulatory care settings - a systematic review
Heselmans A, Van de Velde S, Donceel P, Aertgeerts B, Ramaekers D
Implementation Science 2009, 4:82 (30 December 2009)
[Abstract] [Provisional PDF]

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.