Healthy Policy

Three cheers for Kansas!

My home state of Kansas is undertaking a new health information technology (HIT) program:

A new test program in Wichita may someday lead to the storage of all personal medical records online, easily shared among hospitals and physicians.

Wichita health care providers are helping pioneer a state pilot program that creates a centralized patient database of medical information, setting the framework toward a national exchange of health information.

State officials and their partners plan to publicly announce the project today, although it quietly launched in February to assess viability.

Called the Community Health Record Pilot Project, the demonstration moves Kansas another step forward in creating a unified electronic medical records database.

"We're really interested at the state level in seeking ways to improve the health information exchange that goes on between practitioners and hospitals," said Robert Day, interim executive director of the Kansas Health Policy Authority. "Everybody sees it as a really critical transformative process."

The pilot will use claims data of patients in Kansas Medicaid's HealthWave program, maintained by FirstGuard.

Although there is a delay between when claims are processed and uploaded to the database, historical data going back about two years has already been submitted to Cerner Corp. of Kansas City, Mo., which supplies the online database technology.

The total cost to tax payers is estimated at $750,000 and half of that will come from Medicaid.  A good investment, and one that can hopefully be extended to other health systems in the state in the next few years.

Doctors, start your tablets

When I talk with people (even health policy people) about ways to implement more technology into health care, like doctors using computers during appointments, I get some interesting answers.  Like computing while seeing patients will destroy the doctor-patient relationship.  This answer is quite puzzling, as the doctor-patient relationship is pretty mutilated already, and the benefits of direct computing by physicians (cost, time, efficiency, and most important: reduction of error), seem to outweigh the discomfort of your doctor occasionally typing things in.

But (via the Health Business Blog), Microsoft is introducing a new product that can quiet this debate with one fell swoop:

The Microsoft Origami Project seems to be a nice little tablet-style PC along the lines of the Motion Computing LS800 that I have described before. It's the kind of hardware that makes electronic medical records, e-prescribing and decision support tools all the more practical for physicians by making it possible to carry a full-featured device in a lab coat pocket.

And I'd add, without a big screen that apparently perverts the essential nature of physician care.

New webMD records

From the Great Ideas in Technology Bin:      

The New York Times on Thursday examined how WebMD Health, "one of the most-visited medical information sites on the Internet," hopes to "tap into the growing corporate trend of having employees pay more ... of their own health costs" by "helping people enrolled in employer health plans compile personal health information online." WebMD has signed multiyear licensing contracts with health insurers Aetna, Cigna and WellPoint and almost three dozen large U.S. employers -- such as Bank of America, Cisco Systems, Dell Computer, IBM, Pfizer and Shell Oil -- to operate private-access Web sites that allow employees to track their medical records, as well as find information about diseases and compare cost and quality ratings for physicians and hospitals.

I would love to participate in this program, if only because I'm so tired of filling out 5 million forms every time I go to the doctor.  Continuing the cycle of inefficiency, the nurse asks me every single time what medications I'm taking (especially because I take more than one). 

But I also get very curious about what they write down about me in my medical record.   Don't you always want to grab your record when the doctor leaves the room for a second and thumb through it?  Now you can. 

Learning from Cerner

HIS Talk has a great post examining what really went wrong with Cerner's CPOE (computerized physician order entry) system. For those of us who strongly believe in the awesome potential of HIT, it's essential to know what went wrong, and what we can do better.

I'm glad they did the study, but it seems to me more of a "don't do what we did" lesson for hospitals, not an indictment of Millennium. I think their purpose was to raise the awareness of broad outcomes in a major system change and the article does a good job of that.

I'm always quick to jump in a vendor-bashing line, but anyone who sees this article as valid Cerner criticism is wrong, in my opinion. I doubt any other vendor would have done better. I doubt every Cerner implementation has these problems. I'm sure that the hospital would make better implement decisions if they were doing it over again, as would most CPOE early adopters.

Go read the original critique by the HIT expert -- it's a valuable discussion of the intricacies of HIT programming and hospital implementation and well worth your time.

Reducing Error

Interesting news on reducing medical errors, via Modern Healthcare:

Data show that a jumbo jet's worth of patients die each day from medical errors, so it is fitting that an aviation comparison was used in a new study of one source of errors--the handoff of patients from one physician to another.

The study in the December issue of the journal Academic Medicine found that unlike among air traffic controllers and other vital safety operations, there are few systems to deal with patient handoff when one physician leaves the hospital and another takes over. The result is that the handoff is routinely botched--the result of poor communication and training and insufficient information systems--with dire implications for patients.

The solution is to teach physicians the handoff process using a model based on principles of adult learning, effective feedback and clinical experience, the study authors say. "Computerized medical records can facilitate face-to-face handoffs," he says. "Body language and other crucial factors are lost when the handoff is done over the phone and a written handoff may be difficult to read--doctors have notoriously poor penmanship--errors especially in numbers or decimal places are easy to make, and written notes are open to misinterpretation or misplacement."

I love the jumbo jet a day analogy because the gravity of medical errors is often prone to understatement. And in the post 9/11 world, extending the analogy further and comparing doctors to air traffic controllers is particularly potent.

But here's what I don't understand. Obviously EMRs can reduce errors, but if what the study authors believe is true -- that there's no substitute for a face-to-face handoff-- they can only do so much.

Along with HIT fixes, we should also be asking how can we facilitate more face to face handoffs. If my recent hospital stay is any indicator, that's no small task. Considering my doctors seemed to be on completely different schedules, and considering the pressure to be as efficient and speedy as possible, it's no wonder this task isn't always accomplished. How can we reduce those pressures, along with additional methods of reducing errors (EMRs), to prevent those 100,000 deaths? Any one of us could be included in that statistic this year. If face-to-face handoffs can't be attained, is it possible to integrate video conferencing technology?

Doing HIT Right

Matthew Holt has an interesting post up on his latest editorial on electronic medical records (EMR) and a physician's response:

My cursory assessment is that electronic records are vital in improving the healthcare delivered to patients, particularly those with chronic illnesses, over the continuum of care. But it's clear that when they're introduced to ICUs or ED, where speed is the key and care processes are not well defined, things may not be so successful. A real examination of the process absent the technology, and a massive commitment from vendors to improve the human-computer interface, is quickly needed before the movement toward CPOE and EMR is stopped by these kinds of stories. After all, it's easy for a hospitals or physician groups to decide instead to do nothing.

Matthew really sums things up perfectly. As the Children’s Hospital in Pittsburgh demonstrated, installing a CPOE is not even half the battle.

Many of us are familiar with the triumphalism surrounding HIT development and use. But one cause for concern is the apparent lack of standardization going into the implementation of EMRs. This Health Affairs article noted: "effective EMR implementation and networking could eventually save more than $81 billion annually—by improving health care efficiency and safety." While the move to adopt HIT is progressing at a snail's pace, all that extra time is just adding up to extra problems. Obviously different hospitals need different operating systems, but without standardization in something as basic as the medical record, we can kiss a good chunk of that $81 billion good-bye.

Matthew's commenter replies:

The move toward EMRs is not being led by physicians or hospitals, so our input is amazingly irrelevant. The movement is largely based on a fallacy that improved technology will lead to decreased cost, with a side bar of improved quality of health care. It is led by business interests and followed by the government - ie, the payors. Improved technology will be a huge boon for consulting firms, administrators, and other types of technician and advisors. It will absolutely not decrease costs. Only improved rationing of health care resources will do that.

This physician makes a great point in that the move toward EMRs isn't led by doctors or hospitals, but by communications people, analysts, insurance companies and health policy wonks. That's a problem. As much as physicians are proving supremely difficult to bring along on the ride, there are just too many instances of resistance and error to keep doing it that way. I've called for it before, but we have to ensure medical practitioners (not just doctors, nurses will be doing the bulk of the work) are deeply involved in the development of this software.

The one thing I don't get from this commenter is how she can say with such authority that "It will absolutely not decrease costs." What's her basis for that, given the huge mountain of research suggesting otherwise? Again, we have to ensure our HIT implementation is done right, with some standardization and ample input from practitioners, but even with stumbling along the way money will be saved. Savings are estimated in the tens of billions -- we can't afford to mess this up. And the money isn't nearly as important as the lives that will be spared from medical error and the quality of life improved thanks to better care.

We Can Do Better

MedPundit says:

Count me unconvinced that computerized records will be the savior of medicine. It's just managed care in another guise

Huh. That's an interesting take, I suppose, considering the most recent Health Affairs research on electronic medical records (EMRs):

Effective EMR implementation and networking could eventually save more than $81 billion annually—by improving health care efficiency and safety—and that HIT-enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits.

Really though, it just seems totally ridiculous to me to oppose something that will obviously save so much money and greatly improve care on principle.
Medpundit even admits the benefits of health information technology (HIT):

Yes, it's a more efficient method of storing and retrieving information. And yes, it's a method of reducing errors, although it also introduces new system-specific errors. The government's paramount goal in pushing a nationally-connected healthcare record is to be able to monitor and prescribe what kind of treatment everyone gets.

A little paranoid, no? If anything it's the insurance companies in doctor's and patient's faces trying to dictate care.

Take my Dad, for example. He broke a bone in his foot. His doctor prescribed a nifty little ultrasound machine that is supposed to stimulate bone growth. He took said nifty machine home with him from the doctor's office and began using it. Three weeks later he gets a letter from the insurance company that this device is not, in fact, covered. Care to take a guess for the cost of this little machine? (It's about 6 inches by 6 inches) $3,000.

No one at the doctor's office mentioned that insurance plans won't cover it. They just gave it to him, and now he owes three grand.

It's one thing to oppose the cost of implementing EMRs and HIT (health information technology) advances, which is why the government is leading the charge (see the VA and recent grants for practices to buy HIT software). I'd like to think things like EMRs could help patients avoid these problems(i.e. the doctor or nurse having a message pop up when they type in a treatment that this patient's insurance does NOT cover this treatment). Of course, if there's only one insurer we take out the guess work.

But simple ideological opposition to HIT exposes a disregard for quality care and selfish concern for the amount of hassle in learning a new system.