What Can An iPad Scrabble App Teach Us About HIT and EHRs?

It sure isn't easy being a President nowadays. Arab potentates have the bad taste to not know when they've been conquered, U.S. Treasurys could be downgraded, the U.S. air traffic control system literally takes naps from time to time and the health care reform debate refuses to go away. ACOs, the centerpiece of the "bend the curve" potential of the Affordable Care Act, may end up not having much of a reach or be readily embraced by physicians.  And in the middle of all that consternation, the Disease Management Care Blog was confronted by an additional lesson on the limits of the Administration's investments in health information technology (HIT).  The DMCB was visited by two of its spawn this weekend, who spent a pleasant afternoon on either side of the living room sipping chilled beverages. Playing Scrabble.  Remotely.  Over the Internet.  Using their iPads.  The only recognizable human interaction was the trash talking.

How... cool.

Which may ironically be more bad news for the Feds' efforts to promote use of electronic health records (EHRs).  Go to this CMS web site and it's clear that the vision underlying EHRs is an encounter-based system involving providers who maintain a central repository of patient-specific information and use that "platform" in "meaningful" ways. The Stage 1 "meaningful use" (MU) criteria outlined here confirm it's all based on a standardized and traditional clinical approach.  In that MU world, key information (problem lists, medication history, health screenings) is  maintained, followed and shared among the providers with a need to know.  It is very specific, measurable, transactional and reductionist.  Instead of an old-fashioned Scrabble board, it's on a monitor - but it's the same old game.

It is also ill-suited to the attitudes and lifestyle of the future patients who took over the DMCB living room.

While experts flittering about the "HIT space" refer to "ecosystems," the DMCB suspects that description may be far more apt than is generally appreciated.  Ecosystems are not linear, they're complex with interactions that are greater than the rum of their parts. This is where denizen patients and providers use multiple technologies reliant on rapidly evolving portable platforms to collaboratively and bidirectionally interact in real time.  Problem lists are jointly agreed to, medications are ever-shifting and health data are being constantly updated.  Docs will not only need to personally interact with their patients, but docs' portable information-devices will be syncing with their patients' while decision logic spins in the background.  Think about seeing a doctor as the two of you initiate your devices and trigger a dedicated and shared "app."  That is a truly new version of Scrabble.

Of course, the IT weenies will argue that EHRs need to learn how to crawl before they can run.  The DMCB agrees, but wonders if CMS' heavy handed involvement is forcing the system to crawl over problem and medication lists, while EHR-enabled interactivity remains the exception and not the rule.

Undoubtedly, minds far more creative than the DMCB's and the government's are already pursuing a new "Scrabble-oid" HIT paradigm. When they achieve a workable model, will the MU's specific, measurable, transactional and reductionist maintaining, following and sharing of problem lists, medication lists and health screenings get in the way? 

So Many News Events, So Little Blog

Why Not Fast Track the ACA to the Supreme Court?

The Disease Management Care Blog asked the same question as Senator Nelson in this quixotic post weeks ago. The real news is that as a lawyer, the Senator has shown there is an exception to every algorithm.

Career Management 101

The DMCB understands the best time to exit any position is while your reputation is high and before things start going bad. That may be the intentional or unintentional thinking behind Dr. Blumenthal's decision to exit, but that doesn't make it any less true. As studies begin to show that the EHR stampede is not leading to higher quality or lower costs, explaining that sorry news will become the duty of a third HIT Czar.

A Vice President for Patient Centered Medical Homes

All well and good, says the DMCB, but the PCMH will not have truly achieved the pinnacle of corporate medical-industrial success that it so richly deserves until a major health system identifies a Chief PCMH Officer, or CPCMHO for short.

This Is How We Make a Health Law Better?

There's the cost of the ACA and then there is the revenue necessary to fund it. Repealing the 1099 provision addresses only half of the problem. The DMCB fears having Congress oversee the fiscal integrity of the ACA is like having Charlie Sheen emcee a spring break party.

1000 Posts!

Last week, the DMCB broke the 1000 post barrier. Really.

Here's a Whopper of a Prediction from National Coordinator Blumenthal About the EHR That Hasn't Quite Worked Out

'Tis the month when journalists, pundits, bloggers, wonks and the other denizens of the commentariat examine past predictions and make new ones. So, when a new research article on the merits of the electronic health record (EHR) came out, the Disease Management Care Blog couldn't help but recall this whopper of a forecast:

"The widespread use of EHRs in the United States is inevitable. EHRs will improve caregivers' decisions and patients' outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice."

That's from national coordinator for health information technology David Blumenthal writing in an August 2010 issue of the New England Journal. The Disease Management Care Blog can forgive him: as a Czar presiding over our national medicaltechnologic complex, cheerful blather is part of the job description and part of the Washington m.o.

Facts, on the other hand, are a different matter. The latest example that EHR adoption is not the Utopian panacea that the HIT weenies would have you believe is this RAND article authored by Spencer Jones, John Adams, Eric Schneider, Jeanne Ringel and Elizabeth McGlynn (yes, THAT Elizabeth McGlynn) titled "Electronic Health Record Adoption and Quality Improvement in US Hospitals."

The authors cross-referenced survey results (including having a basic or more advanced EHR system in place) from the Health Information and Management Systems Society (HIMSS) with the quality data from the American Hospital Association's Hospital Compare. The hospitals used for the study were the 3971 nonfederal general acute care hospitals. The quality measures assessed treatment of a heart attack, heart failure and pneumonia. If Dr. Blumenthal's above bluster is correct, more EHR in each of these US hospitals should translate into clinically and statistically significant increased quality, right?

Not exactly. From 2004 to 2007, there were 4-16 point performance increases in treatment of heart attack, heart failure and pneumonia in the 62% of U.S. hospitals that didn't have an EHR in place. Compared to these "no EHR" hospitals, there was no difference in the hospitals with a basic EHR or an advanced EHR - with one exception (treatment of heart failure was better among those with a basic EHR).

But wait, it gets worse. Heart attack and heart failure quality scores statistically improved less among hospitals that adopted an advanced EHR compared to hospitals that did not adopt an EHR. What's more, heart attack and heart failure quality scores improved significantly less in hospitals that upgraded their basic EHR compared with hospitals that maintained their basic EHR.

To their credit and to Dr. Blumenthal's minions' relief, the authors point out that their study was short term, was limited to a narrow set of quality measures in select hospitals; it didn't capture all possible quality measures in all health care settings. In addition, the authors note that there's a difference between having an EHR and fully as well as correctly implementing it. It's possible that a well implemented EHR does lead to real quality. It's also possible that measures of quality in heart attack and pneumonia may have reached their ceiling, making it more difficult to detect any meaningful changes one way or another. Last but not least, the authors speculated that the considerable work of installing an EHR distracted the hospitals over the short-term from continuing to work in quality improvement and that there will be a pay-off in the coming years.

Despite these limitations, the results should give pause to policymakers that have bought into the notion that EHRs will "inevitably" fix all that ails U.S. health care. In addition, this study may warn us that complicated systems lead to complicated problems; when it comes to EHRs, the truth may be that less (like computerized physician order entry or medications, lab review) is more. EHRs may eventually improve caregivers' decisions and patients' outcomes, but this study shows patients have yet to consistently experience the benefits of this technology for heart attack, heart failure and pneumonia. The truth is that there are hundreds of thousands of physicians have not seen these benefits in their clinical practice.

Dr. Blumenthal may wish to reconsult with his crystal ball.

The "Water Water Everywhere, Nor Any Drop To Drink" Problem of Electronic Health Records (EHRs)

As further evidence of the growing mojo of the population health (née disease) management industry, go no further than the ability of the Care Continuum Alliance's Forum10 to attract speakers of national stature. Case in point was the October 13 appearance of National Health IT Coordinator David Blumenthal. This was the second time the Disease Management Care Blog saw him speak. He was just as measured, serene, confident and mistaken as he was the first time.

Listen to the rhetoric of Dr. Blumenthal and others like him, and it's easy to get the impression that the U.S. on the cusp of joining the rest of the civilized world in a new computer age of medical efficiency, englightenment and safety. If you believe them, it seems a major hurdle toward this era of electronic enchantment is being overcome by the enlightened application of meaningful use criteria coupled with provider financial incentives.

Yet, when the DMCB talks to physicians from smaller practices, it hears a recurrent and contrarian theme that matches news reports: they are actively shopping electronic health record (EHR) vendors but, so far, the offerings disappointingly fall short in ease of use, have marginal point-of-care decision support and don't generate significant patient value. While they stand to get some serious money, their calculus also includes the bitter past lessons of promises broken while struggling to keep their patients healthy and satisfied. As for the large medical groups, one read of Health Care Renewal's collection of depressing stories of endless HIT hubris, waste, mismanagement and patient harm should be enough to give any reasonable person pause.

Yet, before you think the DMCB is being an neo-Luddite weenie, let it be the first to agree that the fact that docs are now actively looking EHRs tells us something. It would appear that conversion away from paper records may be reaching a national tipping point. The DMCB thinks there are two reasons: 1) the drumbeat of Medicare money can't be ignored, and 2) the shift of some docs in some regions into larger physician practices is enabling those groups to accumulate sufficient capital for an investment in HIT.

Of course, as that happens, non-readers of the DMCB will make some painful discoveries. EHRs with or without "meaningful use" have little hope of controlling costs, don't necessarily increase quality, have little impact physician or patient behavior and trade new problems for the old ones.

But, says the DMCB, none of these are the Achilles heel of the metastasizing medicalinfotechnology complex. Rather, the biggest EHR vulnerability is its glut of data with little in the way of any real information.

The growing body of raw data contained in all those EHR servers, if it remains unorganized, will rapidly outstrip the ability of providers and patients to keep up. Drug lists are being cluttered with unimportant or discontinued medications. Past patient histories are becoming a logarithmically expanding mash of rule outs, billing codes and pay for performance buttons. Pop-up prompts, lists, tables and sidebars are diverting attention. Terrabytes of other pharmacy, insurance claims and personal data are being imported like spaghetti being thrown against a wall. Other than some flatfooted nods to organizing some of information into "lists," the emerging "meaningful use" criteria are failing to distinguish between being comprehensive and attaining comprehension. It's like the Rime of the Ancient Mariner: "Water water everywhere, nor any drop to drink" (which explains the graphic above).

Which brings the DMCB to an ironic punchline: this is a problem that will be solved. The change from a "capture all data" to a "assemble all insight" user-interface will enable providers to quickly drill through a patient's information set to find the right (not all) information at the right (not all the) time. When that happens, someone will deserve a Nobel. In addition, an up and coming electronic device that really has the greatest health information technology potential for market disruption will make current paradigm of a health-system dominated EHR obsolete.

That would be the cell-smart phone. More on that in a future post.

The Future of Digital Medicine: Smartphones Will Replace the EHR As the Workhorse Informatics Device In Clinical Care Settings

As a former New Yorker, the Disease Management Care Blog has always had an abiding respect for the Big Apple's taxi drivers. That increased considerably after it left its wallet in a Manhattan cab and it turned up in Virginia a year later - in the possession of an individual allegedly involved in organized crime. This and other evidence of the cabbies' shrewd business acumen makes the DMCB wonder why Hizzoner required that they start using hybrid cars. If they're such a gas-conserving and money saving no-brainers, the DMCB figures the cabbies would have figured out a way to get them on the streets all by themselves.

Which brings the DMCB to smartphones and healthcare. How can this be, you ask? Read on.

Thanks to the Covering Health blog and their link to this report from the California HealthCare Foundation (CHCF), the DMCB not only got to delight in the new term 'techfluentials,' it learned that these little electronic mini-slabs have remained remarkably recession proof. They're now in use by 42% of consumers. Even more impressive, however, is their uptake among supposedly tech-wary physicians. Fully two thirds of providers currently possess smartphones and that's projected to exceed 80% by 2012.

There are over 5000 iPhone health-related apps and about a third have been designed for physicians and other providers. They include medical and drug reference libraries, dosage calculators, clinical alerts, decision support tools, viewers for lab and radiology reports (including the x-rays themselves), communication portals designed for patients as well as physicians, patient status monitors (for example, in the emergency room and labor suite), continuing medical education (CME) tools and the means to access a patient's personal health record (PHR)

In the meantime, the Feds continue to promote a stubbornly expensive and unwieldy electronic health record (EHR). With their usual complex web of financial and regulatory sticks and carrots, Washington's bureaucrats remain fixated on the big boxy multifunctional and proprietary personal computer-based systems with screens and keyboards populating every clinic room and hallway.

In contrast to that orthodoxy, the DMCB agrees with it's colleague Vince Kuraitis. He predicts the EHR will evolve into a PC-centric platform of distributed cross-functional and plug-and play devices. Yet, thanks to the California Foundation report, the DMCB wonders if things may become even more complicated than that. It could be that the handheld smartphone, not the screen and keyboard, turns out to be the central hub of digital care. In other words, the iPhone won't be slaved to PC-based EHR systems, it'll be vice versa. What's more, there won't necessarily be a desktop or a hallway. In fact, the clinic's boundaries may turn out to be even more fluid than we ever anticipated.

And it's all happening without Federal intervention.

Which brings the DMCB back to the New York City cabbies. Despite the best intentions of the Mayor, there have been problems, suits and delays. The DMCB also recalls reading that the involvement of NYC government in the first place may have ironically led some cab companies, pending better understanding the law, to delay buying any hybrids.

And, despite similarly good intentions extending back through several administrations, Federal meddling in the promotion of EHRs have also caused many physicians to delay the purchase of an EHR. Unlike the NYC cabbies, however, the docs have had another smaller, nimble, cheaper and remarkably functional option. It's the smartphone, which may have been partially spurred by the continuing travails of the Fed's love affair with the EHR. It seems that while providers have been waiting for Dr. Blumenthal et al to clarify just how good the EHR can be, physicians have apparently turned to the next best thing.

In fact, based on CHCF's report, it may be turning out to be the better thing.

('’)

Tell The Feds What You Think!

Do you think patients getting timely copies of their electronic records, after-care summaries for each encounter, discharge summaries for each hospital stay and patient reminders for preventive as well as follow-up care are what it takes to provide state-of-the-art care for patients with chronic illness? '

The Disease Management Care Blog doesn’t think so either. The good news, however, is that it and you have an opportunity to let the Feds know why those elements are a good start and are necessary but are still insufficient. You can do so at the Health Information Technology “Federal Advisory Committee Blog” here.

That’s right, the Feds have posted a series of questions that are calling out for your on-line input. The questions range from use of the PHR, leveraging the EHR as a means of collaboration, workflow and data management.

Comments placed today will be used by the Feds in their ongoing deliberations, including an April 20 hearing.

The Detritus of Physicians Copying and Pasting in the Electronic Health Record

"Detritus."

Not only was that a chance for the Disease Management Care Blog to refamiliarize itself with an underused noun (and, er, its spelling), that was the telling term used today by a DMCB colleague to describe the output from a local health system's electronic health record (EHR). He had received a copy of a lengthy consultant-physician's documentation involving one of his patients and was astonished by the blob of past data, prior notes, test results, excerpts, quotes, interpretations and correspondence that had been replicated word-for-word in the course of "seeing" his patient. The terse portions describing what the patient actually said, what the consulting doctor actually examined and what the diagnosis and plan were were inconspiculously buried toward the end of the EHR document.

This was a classic case of electronic record "CoPaGA" i.e., Copy 'n Paste Gone Amok Syndrome. Characterized by repeated highlighting, copying and pasting text from past EHR notes into current notes, the physician-victim attains several goals simultaneously: 1) avoiding the time-consuming work of having to talk to a human being, 2) building a long trail of documentation that portrays faux work effort and 3) justifying a maximally remunerative fee.

Other symptoms of CoPaGA are well described in the medical literature such as JAMA here in the Archives here. They include the crowd-out of useful information by gluts of useless data-text and the endless zombie-like propagation of inaccuracies that refuse to go away. The problem is significant enough that a methodology exists to measure just how severe it is. Last but not least, it's also important to recognize that the words "seeing" and "patients" in context of CoPaGA is a contradiction in terms, since afflicted docs typically spend little time actually looking at patients. They're too busy looking at the monitor!

Contrast this with these New England Journal authors' promise of EHRs preventing diagnositic errors through....

."..serving as a place where clinicians, together with patients, document succinct evaluations, craft thoughtful differential diagnoses, and note unanswered questions. Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient's history and making assessments, and notes should be designed to include discussion of uncertainties...." (italics DMCB).

Will the proposed 'meaningful use' HITECH regulations (which can be seen here) be able to combat CoPaGA and solve the problem of the substitution of input for insight by EHR addled physicians? That remains to be seen, but given the incurabilty of CoPaGA and the eternal nature of detritus (spelled with two t's), the DMCB thinks the prognosis is bleak.

We'll see.

Health Affairs and Their Issue on Health Information Technology: Your DMCB Helps You Take A Tour

If you're mystified by the continuing folderol over electronic health records (EHRs), you may want to head over to your closest medical library and take a look at the latest April 2010 issue of Health Affairs. It has a good spectrum of informative articles on the Feds' efforts to promote adoption of EHRs, the debate on meaningful use, some of the usual pro-EHR fluff, what's going on in physician practices nationwide and - and kudos to the HA Editors on this - some warnings about where this technology falls short. You can read more about the issue at the Health Affairs blog.

Alternatively, since you are one of the thousands of savvy Disease Management Care Blog readers, all you really need to do is get a cup of an appropriately caffeinated beverage, adjust your monitor, sit back and quickly scan this encapsulated summary. THEN you can decide which articles warrant use of your precious time for closer inspection:

In her opening article, Editor in Chief Susan Dentzer points out that only 6% of hospitals and 2% of physicians rely on EHRs and that the Feds are banking on a combination of sticks and carrots to encourage them to adopt "meaningful use" EHRs. She notes the taxpayer's $29 billion investment in the HITECH legislation hinges on getting the definition of meaningful use right.

There's a Health IT Gold Rush Underway, says Nancy Ferris, thanks to HITECH's $750 million in grants and contracts going to 40 States and 30 non-profit organizations that, in turn, are supposed to facilitate health information exchanges and technical assistance. There'a another $225 million going to train people in information technology, courtesy of the Department of Labor. That's just for starters, and a pittance compared to the more than $14 billion that will go to physicians (as in $18,000 per doc per year) and hospitals. You can also get her summary of the five key goals of HITECH and wonder if it will be enough to prod physicians into spending an estimated $30,000 apiece for a functional EHR.

Want a screen shot of what the docs at Kaiser Permanente see when they're taking care of patients? It lists chronic conditions, immunizations, vital signs (including obesity), care suggestions ("flu shot due, Active tobacco use, advise quitting"), recent lab tests and a list of medications.

What happens when you put an ex-national coordinator for health information technology with the current coordinator for health information technology in the same room? After reading this exercise in mutual admiration and closed circular reasoning, the DMCB asks who really cares?

John Halamka is the blogging CIO Beth Israel and Deaconess and likes what he sees in the emerging definitions of meaningful use, but has some suggestions about increased governmental guidance without stifling innovation. Those suggestions include content specificity, creating better vocabulary subsets, better approaches to data transmission, and heightened secruity and quality reporting. This article - by someone well versed on how to use the written word - gives some insight as to why getting into the weeds of health information technology is not easy.

Sean Hogan and Stephanie Kissam of RTI International suveyed 4,484 physicians with a 2,758 responses (an impressive 62% rate). They found that 18% have at least a basic EHR and, depending on the which part you ask about, about 75-85% meet the various individual meaningful use criteria. The DMCB asks how many physicians met ALL criteria simultaneously, a number that was apparently not mentioned in the report. The DMCB also wonders if the other 82% of physicians, after reading this paper, might think they made a smart move by waiting.

James Ralson and other colleagues from Group Health report on that organization's experience with the system-wide implementation of an EHR, a patient centered medical home model of care and a web portal through which patients could view their test results, request medication refills and email their physicians. Before you take the time to read this, the DMCB warns there doesn't seem to be any new insights on how to pull this off outside of integrated delivery systems.

David Bates and Asaf Bitton of Brigham and Women's have some thoughts on how health information technology can be configured to better support the patient centered medical home. While they think the two are inseparable, they have some specific suggestions on how to achieve better clinical decision support, registries, communication capabilities that enable teaming, tracking of hospital discharges, patient friendly personal health records, enabling of remote monitoring and support of quality reporting. The DMCB agrees wholeheartedly, because much of this is already being used to great success in commerical disease management programs.

"Warning!" says Rushika Fernandopulle and Neil Patel, who describe How The Electronic Record Did Not Measure Up To The Demands Of Our Medical Home Practice. With great expecations, AtlantiCare started up a PCMH in New Jersey and found they were stymied by computer slow-downs, e-prescribing security glitches, inabilities to import lab data, clinical alert fatigue, increased physician busy work, too much effort reconciling medication lists, having to rely on an outside vendor, lack of a registry and inflexible on-screen templates unsuitable for non-physicians and group visits. They eventually turned to other software solutions to operate in parallel fashion.

Using "Analtyica 4.1 modeling software", Colene Byrne and colleagues from the "Center for It Leadership" performed a cost-benefit analysis of the Veteran Administration's $7.16 billion VistA EHR. Thanks to projected reductions in adverse drug events, diminished duplicate lab testing, reduced work, decreased operating expenses and more freed space, the cumulative yield in benefits net of costs was $3.09 billion. Before you take the time to read this, the DMCB again warns there doesn't seem to be any insights on how to pull this off outside of the VA, even if you accept the black box analysis.

Catherine DesRoaches and other colleagues from Mass General, George Washington University and Harvard find a poor correlation between hospital adoption of electronic health records and measures of quality. In a companion piece, Jeffrey McCullough and colleagues from the University of Minnesota found a better correlation in hospital quality but many of the outcomes failed to reach statistical or even impressive clinical significance. After reading this, the DMCB wonders if the other 94% of hospitals waiting on the sidelines are thinking they are doing the right thing.

But the debate about hospital-based computerized physician order entry (CPOE) is over, right? Well, maybe not exactly. While previous studies have shown CPOE without a full fledged EHR can reduce medication errors and save lives, Jane Metzger et al show the systems aren't perfect. Using a simulation tool in a sample of hospitals that volunteered to go through this, only 53 percent of the medication orders that would have resulted in fatalities and 10–82 percent of the test orders that would have caused serious adverse drug events were detected. Uh oh.

Oh, never mind says Susan DeVore and Keither Figlioli of Premier health care alliance. They surveyed their hospital members and found the road to EHR installation is lined with gradual implementation to account for objections and work-flow hiccups, clinical champions, lots of staff training, meaningful quality-based decision support and reporting, high security, clear policies and budgets that can handle the unexpected and pay the clinical champions.

Phyllis Torda, Easther Han and Sara Hudson Scholle of the NCQA interviewed 'knowledgeable people" about the implementation of EHRs and found no problem cannot be solved by assistance, consultants, trust, engagement, expertise, sophistication, realism, operational excellence, program redesign, selection of the right software and hardware and sustainability. See... it's that easy! Check out the list of insider knowledgeable people and you'll see why.

Alan Hinman and David Ross go back to the fundamentals and review the building blocks of EHRs, health information exchanges and immunization registries, suggesting the latter may be a good way to tie everything together. The DMCB thinks there may be something to this learn to walk before you run approach.

Good grief you made it to the end of this summary. If you are that interested in the topic, the DMCB suggests you head on over to Vince Kuraitis' e-CareManagement Blog where he has inaugurated a series of very informative posts on HITECH.

Value Based Insurance Design and the Synergies with the Medical Home, P4P, HIT and Disease Management. We've Only Just Begun

More than a year ago, the Disease Management Care Blog posted a prediction. It said that the key to achieving improved population-based outcomes at lower cost will lie in the combined five-fold synergies of: 1) Ver 2.0 care/disease management, 2) the patient centered medical home (PCMH), 3) provider pay-for-performance (P4P), 4) the electronic medical record (EMR) and 5) consumer directed health plans. It turns out that the DMCB was slightly wrong in several domains. It's not necessarily just 'pay for performance' but flexible provider compensation that includes enhanced fee-for-service, risk-adjusted capitation, P4P and gain sharing. It's not just the EMR, but EHRs plus decision support and registries. And it's not consumer directed health plans but value based insurance designs (VBID).

What is VBID? It's any commercial insurance product that includes adjustments of patients' out-of-pocket costs and provider reimbursement for specific services based on their clinical benefit. The greater the benefit to the patient, the lower that patient's cost share and the higher the provider payment. It can be tailored to certain services (for example, lipid testing) and/or for certain conditions (diabetes mellitus) and/or condition severity (enrollees with recurrent hospitalizations) and/or level of participation (in care management). It's not necessarily easy to implement, since there are Federal and State regulations to consider, the possibility of employee push-back over perceptions of unfairness, a still evolving business model and questionable scalability across a network.

You can read more about it here and view this helpful YouTube video here.

VBID was an important topic that was discussed by Mark Fendrick at the Patient Centered Primary Care Collaborative Stakeholder's meeting that was held in Washington DC on March 30. His presentation (the PowerPoint is not yet available on line) was timed to match the release of this PCPCC white paper. It's worth downloading and reading. It describes in some detail how the PCMH and VBID can be integrated through reduced patient out-of-pocket expenses for medical home-based visits as well as for referrals coordinated by the medical home, increased health reimbursement/savings accounts to pay for medical home services and co-pay tiering that favors testing and medications ordered by medical home team members.

The March 30 meeting also featured Dr. Blumenthal of ONC, who spoke rather extensively about the synergies of health information technology (HIT) and the medical home. Unlike discussion of VBID, however, there was little else that was particularly new in this discussion, including the assertion that this time, and we really REALLY mean it this time, that "meaningful use" combined with luster of federal funding will cause all those hold-out physicians relent and spend tens of thousands on an outpatient EHR.

What was missing from both Dr. Fendrick's and Blumenthal's presentations, however, was how HIT, VBID and the medical home are probably more than the sum of any of its parts. For example, HIT-based decision support tapping into registries can help prompt value-based interventions coordinated by PCMH team members even if the patient is not physically present.

The DMCB says toss in the right kind of provider reimbursements and the option of distance telephonic support to help coach the patient using principles of shared decision making and....

Well, the DMCB thinks anyone can see the potential here.

Years ago, the DMCB also submitted a paper to Health Affairs on the topic of an overlapping and mutually supportive five-way approach to population-based care. After some tantalizing positive reviewer feedback and requests for revisions, it was ultimately rejected. The thinks it was ahead of its time. The manuscript is in some folder in the DMCB World Headquarters somewhere. Maybe it's getting time to dust it off.

And maybe at a next PCPCC confab, it'll be realized that PCMH-VBID or PCMH-HIT dyads are only the beginning.

A Report on the Electronic Record and a Report on the Patient Centered Medical Home: Good Reading

The bookish Disease Management Care Blog found two recent and interesting pieces from the medical literature for your consideration. One deals with the electronic record and the second deals with medical homes. Both are written with the physician incentives in mind and deserve to be considered by policy-makers and anyone with 'line' responsiblity for dealing with either of these two initiatives in a provider network.

The first is from David Kibbe MD, a senior advisor to the American Academy of Family Physicians. Writing in an online 'ahead of print' version of Family Practice Management, Dr. Kibbe offers up some words of caution over the latest plan (proposed rule making) by the Feds to promote the 'meaningful use' of the electronic health record (EHR). This should give pause to policy makers that think the EHR is a wonderful idea that only needs a nudge to make it become reality in every corner of every physician practice.

Basically, he says, the Feds' latest actions have raised even more uncertainty. As a result, physicians without an EHR may elect to sit tight and use paper for at least one more year or longer. According to Dr. K, here's why:

1. emerging 'meaningful use' requirements by the Feds will force EHR vendors to reconfigure their wares, which is leading to future price uncertainty. (Ditto for the docs that were brave enough to invest in EHRs, by the way).

2. health reform has been slowed, leading to additional uncertainty about future physician fee schedules, revenue and their ability to afford investment in an EHR in the first place.

3. 'modular' EHR-like components are around the corner, which will allow docs to assemble 'clinical groupware' into a functioning EHR, which raises additional uncertainties.

4. the Physician Reporting Quality Reporting Initiative (PQRI), another CMS program that promised to reimburse physicians outside of the normal fee schedule 'P4P style,' has not gone all that smoothly. Docs may doubt that the government can really deliver the goods, er, make that checks.

5. money aside, it's just a big hassle to deal with Uncle Sam

6. the meaningful use process will eventually require the on-line submission of quality outcomes data. Right now, it's not clear how CMS will handle what promises to be a huge data load, introducing even more doubt about the promise to pay physicians in a timely manner.

7. the Feds are threatening penalities down the road for physicians that don't comply with meaningful use EHRs. Many physicians may respond by planning on using paper until that date and then simply retire from practice altogether (when the economy eventually turns around and the 401k's get back)

The second article is available (subscription required beyond the abstract) at the Annals of Internal Medicine. Recall that advocates of the Patient Centered Medical Home (PCMH) suggest that physicians who offer it should be reimbursed with a monthly and risk-adjusted fee per PCMH enrollee in addition to the usual fee-for-service payments. If that sounds like 1990's style capitation, you're right. Written by Ann Mirabito and Leonard Perry of Baylor, the article presents three HMO mistakes that need to be avoided by capitated PCMHs:

1. resist the temptation to go along with any mandated patient enrollment in medical homes. If PCMH's work so well, they should have no problem attracting patients by acting as a 'trusted' guide to navigating referrals in a patient-centered and evidence-based manner.

2. early HMOs were regarded as patient friendly, but things quickly turned sour when there were too many patients and things turned impersonal. Physician practices without the capacity to truly be medical homes will need to resist the allure of signing up too many patients and grabbing all that capitation revenue.

3. simple risk-adjusted payment systems will simply reward physicians for signing patients up. Better to include meaningful dollar incentives that reward measurable quality.

A Top Ten List of Medical Uses for the iPad: An Alternate Point of View

The Disease Management Care Blog is not surprised by the fawning adulation of the health information technology (HIT) minions over the illusory potential of Apple's iPad to 'transform' clinical practice. For example, this CIO posting examines its potential to 'revolutionize' healthcare, while this one says it can become the 'No. 1 tablet.' Toss in jargon like 'point of care tool' and 'personal health device' and add some lusty excitment over applications both real and imagined, and it's easy to succumb to the seduction of touching screens instead of patients, managing data instead of diagnoses and being digital instead of doctors. Never mind that a consistent link between electronic record use and health care quality remains as elusive as the CFO-like DMCB spouse's willingness to approve the expense of a dinner in the Circular Dining Room. It's still cool! It's still neat!

Of course, the iPad hoopla (including the Moses themed cover of The Economist) has only fueled that favorite of internet-media-bloggy punditry, the 'Top 10' list. For example, the Top 10 What You Need to Know and... well the list goes on, including a Top 10 list of Top 10 lists. Within the healthcare arena, the readers of KevinMD's blog were subjected to a dose of unreferenced and wholly speculative Top 10 healthcare iPadmania.

Not to be outdone, the DMCB - based on past experience with electronic records, their starry-eyed administrative support teams, questionable outcomes and the cold hard reality of actually taking care of patients - is pleased to offer its own Top 10 list of potential iPad uses in typical practice involving busy doctors and sick patients in a place unknown to many of the electronic record nobility. That place is called 'the real world':

1. Hot Beverage Insulator: The DMCB used to perch a prescription pad on top of its coffee cup to help retain heat between seeing patients. The disadvantage is that, as a result, the liquid often tasted from cardboard. The iPad case promises to be far more inert.

2. Instrument Tray: Office assistants can lay out scapels, scissors, swabs and other doo-dads on the screen for easy access. Compared to the price of medical equipment such as trays etc. in general, the DMCB suspects the iPad will be quite cost competitive.

3. Lunch! The DMCB learned from a wise colleague that no matter where you are in the day, lunch is always on the way. The iPad will be a boon to any physician who needs to place a lunch order during the tedium of patient care.

4. Tricorder: Remember Star Trek's Dr. McCoy and his multi-purpose diagnostic tricorder? If physicians are confident nothing is wrong with the otherwise dubious patient, point the iPad (or better yet, hold it up against the patient's body), peer intently at the screen and announce there is 'NOTHING WRONG.' Your patients will thank you!

5. Light Source: Surely the iPad's screen can be made to go white. When it does, aim that puppy at the patient and no mole, no body fold and no body cavity will not be amply and completely illuminated. All that's needed is a way to affix it to the doctor's forehead a.k.a. 'hands free mode.'

6. Timer: Most physicians and their administrators understand down to the second just how much time should be allocated to each patient to maximize practice income. The iPad will calculate current billings, cash flows, visit intensity and room-to-room pace to optimize maximum physician efficiency. When 30 seconds are left for that Level 4 visit, count on your iPad to buzz annoyingly.

7. Meaningful Use Standards: Like you, the DMCB doesn't really grasp CMS' Meaningful Use Standards' that will be linked to physician payment for EHR use either, but it thinks having an iPad will magically make it happen. Turn that baby on and wait for a check from Uncle Sam

8. Door Stop: Nothing annoys patients more than being put into a room ahead of time and being left to languish while the doctor is behind schedule. Not a problem, the iPad can be used to prop the door open so that patients can see out into the hallway.

9. Pass Time: Or, if patients prefer, they can leave the door closed and curl up with the iPad edu-tainment device, accessing functions like soothing music or really gross pictures of patients afflicted with weird medical diseases.

10. Cool and Cheap (relatively at least): OK, let's assume patients think you should use an electronic record, but you don't want to shell out the tens of thousands of dollars. Pretend to use an iPad during your patient encounters and you will give the appearance of being cool, connected and networked, even though what you're really doing is surfing and checking the Disease Management Care Blog.

('’)

Informed Refusal: The Doctor Told Me To Come Back When I Had Health Insurance

You're probably familiar with this unlikely and oft-quoted scenario. Patient with disease sees doctor, who peforms a wallet biopsy. After determining the hapless sap is unlikely to pay for the needed medical diagnostic procedure or treatment, the doctor says 'come back when you have health insurance.'

At least that's what the media says.

The Disease Management Care Blog thinks the reality is far more complex:

Doctor: 'How can I help you?'

Patient: 'I saw blood in my [insert name of body fluid] .'

Doctor: 'You're going to need additional testing.'

Patient: I don't have health insurance, so how much is it going to cost me?'

Doctor: 'Well a [insert name of organ]oscopy will cost [insert number] [insert hundreds or thousands] of dollars.

Patient: 'I can't afford that.'

Doctor: 'You can't afford not to have that. Get it done and worry about paying for it later. I'm sure something can be arranged.'

Patient: 'It isn't going to happen. No way can I pay for it, I'm already up to my ears in debt.'

Doctor: 'The test can't be done for free. I strongly advise you to get it done'

Patient: 'No can do.'

Doctor: 'Well, why don't you come back when you have health insurance.'

Years later, when the patient's cancer has progressed to its terminal stages, he is asked how the early symptoms were ignored. The patient's response:

'The doctor told me to come back when I had health insurance.'

The Disease Management Care Blog has seen many patients without health insurance and never dismissed them after a negative 'wallet biopsy'. The typical physician doesn't either. Instead, after confronting the sticker shock of today's real health care costs, it's the patients who often chose to forgo their physician's recommendations based on financial considerations. Weeks, months or years later, what patients remember is how their lack of health insurance put affordability out of reach.

It's been known for a long time that patient recall of the details of past physician encounters is often at variance with what is written in the medical record. When it comes to smoking cessation counseling, this study indicates patient recall tends to be high. On the other hand, recall about the details of the advantages and disadvantages of spinal surgery can be surprisingly low. To complicate things further, recall may be influenced by ethnicity. Of course, not only is patient recall inaccurate, but physician documentation of what happens during the course of a clinic visit often leaves much to be desired. Fixing this shortcoming (for example, with the use of decision supported 'smart forms') is among the many supposed advantages of the electronic record.

The DMCB searched the published literature to see if there were any studies that compared patient recall of the details of what physicians really say about their patient's lack of insurance, what they write in the medical record and what their patients actually remember. There are none. Given the media's less-than-perfect track record on reporting health care in general, the problem may be way overblown.

Some potential solutions:

For the young academics casting about for a research project: use the same 'patient recall' methdology used on prior studies to scientifically compare what really happens to what patients remember in 'no health insurance' discussions. This is very publishable.

For news media: understand that what patients tell you about past conversations with physicians can be inaccurate, if not superficial. Ditto what physicians write in the chart. You are doing a disservice if you give into your biased assumptions and don't dig deeper.

For physicians: if a patient has no health insurance refuses a recommendation on the basis of out of pocket costs for lack of health insurance, approach it like your would informed refusal and take the effort - as always - to document everything. Since physicians typically say much more than 'come back when you have insurance,' the misinterpretation of that phrase makes the DMCB think it should be abandoned and never used in a medical record (unless thats what you really said, you heel).

For electronic health record vendors and CIOs: Develop a 'smart form' that can be used by physicians when they are treating a patient who refuses a recommendation due to financial reasons. For example, 'After discussion of the risks, benefits and alternatives to [insert name of test, diagnostic procedure or treatment here] including the possibility of disease progression and death, the patient, due to financial considerations and the lack of insurance coverage, decided to forego my recommendations. The patient was informed about the need to seek alternative financing alternatives and indicated understanding about that need. The patient was strongly encouraged to return in the near or distant future if there is any change in the decision to forgo my recommendation because of financial considerations.'

For readers: Next time your read about an anecdote about greedy physicians telling patients to come back when they have insurance, be skeptical. There is probably far more to the story.

There's HIT Dogs and Cats, and Then There Are the HIT Skunks

In the latest New England Journal of Medicine, David Blumenthal, who has been named the new National Coordinator for Health Information Technology (HIT), has a “Perspective” piece on the roll-out of electronic records throughout the healthcare system. It has a brief useful summary of the provisions of ‘HITECH’ (the HIT parts of the recently passed stimulus package). Dr. Blumenthal then goes on to make three telling points about how little time there is, the work necessary to define ‘certified’ and ‘meaningful,’ and Congress’ real intentions.

The first is that the National Coordinator is facing a daunting time schedule. Considerable regulatory and program infrastructure needs to be put in place in the next two years and the clock is counting. The bureaucrats will need to move at relative D.C. light speed.

Secondly, while the stimulus law is aimed at promoting the ‘meaningful’ use of ‘certified’ electronic records, no one is quite sure what that means. Dr. Blumenthal points out that yielding to temptation and setting regulatory bar too high may cause physicians and hospitals to ‘rebel.’

But the most important point is that Congress is filled with what my colleague, Vince Kuraitis of the e-CareManagement blog, has ably described as HIT ‘dogs.’ Not meant to be pejorative, this is in contrast to the HIT ‘cats.’ The canines believe health care reform aimed at improvements that are facilitated by HIT will lead to greater use of HIT. The felines believe that’s backwards. They favor reform aimed at directly promoting HIT, believing that will lead to greater healthcare quality. While the written law is decidedly cat-like (thanks to direct physician subsidies for adoption via Medicare and Medicaid, reduced fee schedule payments for the laggards and the financing of regional health information exchanges as well as regional technology extension centers), the DMCB gets the doggone impression from Dr. Blumenthal that this is just the opening scene of a far more involved three-fold Federal agenda. Washington is not only rabidly on the trail of 1) bringing costs to heel, b) licking the number of uninsured but (and here’s the dog part) c) taking a bite out of low-quality care. HITECH is a first step in that direction. No wonder there’s been no paws in Congress’ intense efforts to assemble a health reform package.

But enough of cats, dogs and puns. The Disease Management Care Blog would like to introduce readers to a third HIT species: the skunks. Like Harvard’s Drs. Groopman and Hartzband who decry elegant exercises in wishful thinking about HIT in their Wall Street Journal editorial ‘Obama’s $80 Million Exaggeration.’ Like Columbia’s Dr. Armstrong-Coben, who struggles with a clunky interface that impairs doctor-patient relationships in her New York Times editorial ‘The Computer Will See You Now.’ Like orthopedic surgeon Dr. Haig, who points out in a Time Magazine article titled ‘Electronic Medical Records: Will They Really Cut Costs?’ that the answer is no, because they enable docs to document more billable stuff without any commensurate meaningful increase in quality. Like the University of Minnesota’s Drs. Parente and McCullough who point out in an article titled ‘Health Information Technology and Patient Safety: Evidence from Panel Data’ in Health Affairs that electronic records by themselves outside of large institutions will likely have a small impact on patient safety.

The DMCB apologizes in advance to these and other writers that object to being associated with something so… stinky. But think of Looney Tunes’ Pepe Le Pew and his relentlessly inconvenient pursuits of Penelope. While he often failed, he nonetheless succeeded once in a while. More importantly, Pepe will always be remembered for being true to himself and refusing to accept the wrong answer.

The likelihood that Dr. Blumenthal and Congress will find the right HIT answer? The DMCB thinks that remote. However, if they mess this up, there will be no escaping the smell.

A Video On Electronic Health Records Teaches Us About Its Many Shortcomings

The Disease Management Care Blog thinks that Wall Street Journal Health Blog unwittingly posted a highly instructive video that demonstrates much of what is good, bad and downright ugly about the electronic health record (EHR). The posting superficially describes a reporter’s cross country trek and he happened upon an “Ohio primary-care doc” using a record system envisioned by the Obama team. For your viewing pleasure, the video is posted below:



The DMCB deployed its forensic video watching CSI skills and checked for DNA, fingerprints and carpet fibers. Decide for yourself if its interpretation of the evidence will hold up in court:

The Good: the medications can be electronically transmitted to the pharmacy. The physician doesn’t need to write out the scripts and the patient doesn’t need to wait at the pharmacy window. In the opinion of the Disease Management Care Blog, the efficiency, accuracy and safety of EHR-based medication management are its greatest attractions. That being said, the DMCB isn’t sure its opinion would pass muster with the proposed FCCCER, since the evidence may be lacking. There is no shortage of recent studies saying we still have a way to go. So, let’s say it’s potentially good.

The Bad: Just because an EHR is present doesn’t mean there will be evidence-based practice. Case in point? The first patient in the video has shingles and the physician is prescribing valacyclovir (it fights the virus causing the condition) and ‘gabapentin’ to help with the pain. Unfortunately, the use of the latter drug, gabapentin, for the treatment of active shingles is questionable. The DMCB went to the AHRQ’s National Guideline Clearinghouse and found guidelines that suggest opioids – not gabapentin - be used as a first line agent. Not only is there little evidence that it offers all that much compared to the other treatment options, gabapentin is relatively expensive, the evidence that supports its use is troubled and it may be subject to quantity limits. None of that was shared with the patient.

The Ugly: And just where is the business model locally OR nationally? Is this physician any more efficient than the paper-chart-using doctor down the hallway? Is there better care or higher value packed into this office visit? While viewers may be comforted by the physician’s review of the past immunizations (‘flu shot’), the DMCB thinks that is a monumental waste of time. Ample evidence suggests nurses and pharmacists are more than able to use standing protocols to update any missing immunizations. What’s more, the video cleary demonstrates both patients already know about their immunizations and other preventive care needs. The DMCB ran this video several times and cannot find $20 billion worth of healthcare value or much hope of a return on investment as currently configured.

City State Health Care Systems and their EHRs

Dr. Lesitsky is a community-based primary care physician who practices in rural northeastern Pennsylvania. He's not only a buddy of the Disease Management Care Blog, but someone with a working knowledge of life in the trenches of primary care. When docs like him talk, the rest of us should listen.

By Neil Lesitsky, MD

I am a busy solo family physician located 25 miles from the nearest hospital but within 50 miles of at least 9 separate healthcare institutions. My patients may frequent any one of these or their ancillary branches. In addition, there are literally hundreds of providers within the same radius who are not aligned with any system.

As I see it, each one of these institutions is run as its own City-State, each of which has their own unique monarchs, deities, moats, armies and, most importantly, its own electronic health record (EHR). Each institution treats their EHR as their coin of the realm. This coinage functions well within its own borders but lacks infrastructure to be recognized or connect outside its sponsors’ sphere of influence. The information is locked away in the City-States’ treasuries and inter-treasury transfers continue to require a byzantine process.

One City-State in my area, Geisinger has published a paper demonstrating how its coin has become the gold standard in its region. It makes a compelling case from the viewpoint of that King's Court. From my vantage point, however, the other institutions in my area haven’t necessarily agreed.

Our Government has addressed this issue by suggesting that there be a common language for EHRs, so these City-State realms can communicate with a common diplomatic tongue. However this is not the same as a central treasury. This perspective has also been noted by Rick Peters of the HealthCareBlog in an excellent article noting the difference between standards and interoperability.

In my view, a major barrier to the adoption of an EHR by my primary care colleagues is the lack of a common treasury that aligns the City States in a global infrastructure. In primary care, the attraction of an EHR has more to do with data transfer and preventive care prompts than documentation of care (although my back office may disagree).

There is much more data flow into a primary care office than out of it. In my situation, until such a central treasury exists, and the city states easily transfer their deposits, it is not prudent for me to align myself with any of the monarchs.

Do Computers in Hospitals Save Lives? Reduce Costs? Make the Food Better?

Well, a hot-off-the-press article in the Archives of Internal Medicine says maybe two out of three. Is this a landmark study? Some media reports suggest that's the case.

Given how starved adherents of healthcare technology are for any news that can justify Congressional largesse to the tune of $20 billion, this little gem of a manuscript may garner additional attention in the coming days. If you’re interested in knowing whether computers in hospitals really save lives, the Disease Management Care Blog is at your service with a summary. Another bonus is that you won’t have to rely on the mainstream media to get it wrong.

Dr. Amarasingham (Parkland in Texas), Ms. Plantinga (Bloomberg Public Health), Dr. Diener-West (Bloomberg Public Health), Dr. Gaskin (Hopkins) and Dr. Powe (Bloomberg Public Health) surveyed a variety of Texas hospitals’ physicians about their hospitals’ level of ‘automation.’ The survey they used was the validated Clinical Information Technology Assessment Tool (‘CITAT), which assesses four domains of ‘record keeping, test results, order entry and decision support.’ If 5 or more surveys were completed, each hospital was assigned an average score based on the physicians’ answers. The Texas Hospital Association then provided the hospitals’ data on mortality, costs, complications and length of stay for all patients as well as those with heart attack, chronic heart failure, open heart surgery and pneumonia. A total of 41 of 72 targeted hospitals had 5 or more surveys completed and could therefore be scored and included in this study.

Did high CITAT scores correlate with death rates, cost, complications or length of stay? Well, as the CITAT score increased in each of the four domains, adjusted odds ratios of death and complications for some conditions decreased. Costs and length of stay also decreased for some conditions. Many did not change.

The curmudgeonly DMCB says 'not bad.'

The insight here is that useful inpatient information technology – as defined by physicians, not technobabbly consultantspeak pseudoscience – is associated with impacts on death rates and costs. Importantly, there was a ‘dose response relationship’; as the CITAT increased, the impacts grew. Even better, the insight has greater credibility because it’s gained from real world hospitals, not disconnected academic medical centers authoring studies that are only read in other academic medical centers.

But the DMCB offers up some cautions:

Association is not the same as causality. It is possible that hospitals with the ability to invest in automation also have the ability to invest in nurses, maintain quality programs, attract the high caliber clinical/administrative leadership or leverage other unmeasured features that really account for the observed changes. The authors attempted to statistically control (neutralize) for hospital status, but this is never perfect (the same techniques were used to control for limitations in the same kinds of studies of estrogen in women, which were shown to be mistaken once a prospective randomized trial was done). The bottom line is that there is no guarantee that an install of this kind of IT in year 1 will lead to fewer deaths, decreased complications, lower cost and shorter length of stay in year 2. It might.

This is hardly a slam dunk panacea. The authors noted the swing in mortality rates was in the range of 0.5%. If you’re among those 5 in a thousand, that’s a lot. For the other 995, survivorship doesn’t change. However, those 995 are facing some other issues including never events, being adequately vaccinated, being disconnected from real doctors or being discharged safely. Swings in the amount of dollars numbered mostly in the low hundreds - when an inpatient stay costs thousands and the ambient national healthcare inflation trend rate eats hundred dollar bills for lunch. We don’t know how the savings profited the hospitals or the insurers and, what's more, we don’t know if any profit was greater than the cost of all this IT.

Sorry ye worshippers of the physician office-based electronic health record. This study tested elements of the EHR outside the physician office setting. It does not apply to your vision of a paperless physician office. You’ve still got work to do in terms of providing reasonable assurance that you really save money and reduce costs in that arena.

Multiple comparisons were performed, making the likelihood of statistical mischief greater. Many of the changes were statistically significant (seemed to be of a magnitude that were mathematically unlikely due to random chance) but barely so. To the authors’ credit, they attempted to statistically control for this also and recognized it as a limitation of their study.

The DMCB doubts a single study can answer the question, but this is an important addition to our knowledge base. Good work, authors. Finally, kudos to the Archives for making the manuscript readily available on-line.

The Decreasing Problem of Drug-Drug Interactions Among the Elderly & the Role of PBMs, EHRs & Disease Management. Commentary on JAMA.

The Disease Management Care Blog got a holiday present from JAMA today: an article on the prevalence of major drug-drug interactions among the community dwelling elderly. This was an incredibly detailed and nationally representative study that sent researchers into persons' homes to not only ask what drugs were being taken, but the respondents were asked to go get and show the interviewers the actual drug bottles. In addition, persons were asked about over the counter (OTC) and herbal use.

91% swallowed at least one pill a day. 81% used at least one prescription medication. More than half took more than 5 different pills a day, and about 30% took 5 or more prescription drugs a day.

But what caught the DMCB's eye was the finding that 'one in 25' (or 4%) of study subjects were being exposed to a 'potential' major medication interaction. According to the authors, this corresponds to 2.2 million persons being at risk, which caught the eye of the national media here and here. Sounds like a lot.

The DMCB thinks the real newsworthiness of this report is how low the incidence is. To the DMCB's knowledge, a comparably performed study of outpatients looking specifically at drug-drug interactions doesn't exist. Only half of the drug-drug interactions in this study involved prescription drugs. Contrast that with some representative past studies: drug-drug interactions were more common at 6% in the past among Veteran's Administration outpatients, and among inpatients in Arizona the rate among admissions was 6.4%.

Unfortunately, the authors didn't ask the survey respondents if they received their drugs through an insurance plan, if their prescribing physicians used an eletronic health record (EHRs) or participated in a disease management (DM) program. That's because the data bases of pharmacy benefit managers (PBMs) are being successfully used to identify and prevent interactions. While the DMCB is no fan of EHRs in general, they are good at spotting prescription mishaps. Last but not least, disease management - using registries combined with 'live' person alerts for the prescribing physician - have also been effective in preventing injury.

The DMCB suspects the prevalence of drug-drug interactions nationwide is dropping and it thinks that's because of the market penetration of insurance coverage of medications using PBMs, clinicians' use of EHRs and the activities of DM programs. That's good news.

Post script: This JAMA article also identifies the potential for drug-OTC and drug-herbal problems, which accounted for more than half of the interactions. In the 'real' world of clinical practice, this is very hard to follow because patients (in the opinion of the DMCB) frequently change these agents. While EHRs and the practice of asking patients to tediously list every pill they use at every clinic visit (chewing up precious minutes in a high volume patient 'throughput' setting), a better approach may be covering these agents in pharmacy benefit plans. This is a radical notion, but the coverage doesn't have to be generous. In exchange for the insurance expense, the underlying PBM and DM data bases should be able to spot the other 2% of elderly individuals who are unnecessarily exposing themselves to ills from their pills. While some may be shocked, SHOCKED at the notion of insurance coverage for unproven therapies, the DMCB finds distant public policy parallels here and here.

e-Doubts on Health Information Technology Part 2: Other e-Doubters Weigh In

What’s going on? Since the e-Doubt post, the Disease Management Care Blog is becoming aware of the beginning of a bloggy backlash against electronic health and medical health records. It doesn’t usually write about other blogs (preferring instead to read them) but it appears there’s a critical mass of skepticism in two of the more highly regarded independent health policy blogs.

In this erudite December 17 post in the Health Care Blog, Rick Peters likens healthcare information technology (IT) and its EHR mainframe mentality to the inept U.S. auto industry, only worse. There is one difference though: at least Detroit didn’t try to set up ‘standards’ that unfairly perpetuate their bloated business models. He offers up some extremely sensible, lean and targeted funding suggestions that go far beyond the generalities of the DMCB’s Dec 16 post. He proposes that the Obama Team resist the siren call of EHR zealots and create specific targeted challenge awards that promote scalable, ‘cloud-based’ web-based, secure and open source IT systems that separately accomplish a) insurance claims processing, b) eligibility and claims remittances, c) ePrescribing and order entry, d) laboratory and test reporting and e) decision support. The winners will be rewarded by having all insurers including CMS be mandated to use them. The DMCB says bravo.

In retrospect, the DMCB should have suspected something was up when even blogmaster and e-sage Matthew Holt in this post in the same Health Care Blog noted the electronic health record is ‘not the be all and end all.’ The DMCB likes his concept of limited, mutually supportive and swappable specific ‘applications’ that are designed to either record, personalize, analyze, provide decision support or enable transactions. The DMCB says he who is without the sin of second thoughts should throw the first stone.

And even the taciturn and laconic Maggie Mahr of the HealthBeatBlog wonders if it’s time to call a halt to the e-irrational e-exuberance. Quoting au correspondent several scarred veterans of the healthcare IT contretemps, she discovers real physicians, i.e., the ones that actually take care of patients, don’t necessarily like having EHRs. What’s more, there are a host of other problems including the lack of a business case for interoperability, logarithmic degrees of complexity and toxic levels of radiovendoractivity.

And it may not be just the blogs. According to the December 12 Health Care Renewal post, eternal e-skeptic Scot Silverstein (one of the experts quoted by Maggie Mahr above) points out that the Joint Commission doesn’t buy into the assertion that health information technology is synonymous with safety. In fact, it can be synonymous with mislabeled bar codes, confusing screen displays, poor adaptation to work flows and dysfunctional impacts from loss of professional autonomy. It recommends that safety programs for the EHR be established and has a series of specific suggestions ultimately designed to keep patients from being added to the 98,000 getting killed every year.

The DMCB supposes there may be merit (maybe not) to the overall notion of stimulus spending and, given the percent GDP footprint of healthcare, funneling some serious coin toward health care IT reform would be a heckuva jobs program. Given the insights of Rick Peters, Matthew Holt, Scot Silverstein and the Joint Commission above, perhaps it’s time to ask President Elect Obama and Secretary Nominee Daschle to pause and think again. Can they can really be so confident that $50 billion is a wise investment?