Saturday, January 24, 2009

The Evidence Gap - Health Care That Puts a Computer on the Team

Joseph Calderaro, 67, is one of health care’s quiet success stories. Over the last four years, he has carefully managed his diabetes by lowering his blood sugar, blood pressure and cholesterol with diet, exercise and medication.

To keep on track, Mr. Calderaro visits his doctor, attends meetings for diabetes patients and gets frequent calls from a health counselor. It is a team effort, orchestrated by the Marshfield Clinic here. And it is animated by technology, starting with Mr. Calderaro’s computerized patient record — a continuously updated document that includes his health history, medications, lab tests, treatment guidelines and doctors’ and nurses’ notes.

To visit the Marshfield Clinic, a longtime innovator in health information technology, is to glimpse medicine’s digital future. Across the national spectrum of health care politics there is broad agreement that moving patient records into the computer age, the way Marshfield and some other health systems have already done, is essential to improving care and curbing costs.

A paper record is a passive, historical document. An electronic health record can be a vibrant tool that reminds and advises doctors. It can hold information on a patient’s visits, treatments and conditions, going back years, even decades. It can be summoned with a mouse click, not hidden in a file drawer in a remote location and thus useless in medical emergencies.

Modern computerized systems have links to online information on best practices, treatment recommendations and harmful drug interactions. The potential benefits include fewer unnecessary tests, reduced medical errors and better care so patients are less likely to require costly treatment in hospitals.

The widespread adoption of electronic health records might also greatly increase evidence-based medicine. Each patient’s records add to a real-time, ever-growing database of evidence showing what works and what does not. The goal is to harness health information from individuals and populations, share it across networks, sift it and analyze it to make the practice of medicine more of a science and less an art.

The Bush administration has left it mainly to advocacy and the private sector to introduce digital medicine. But President-elect Barack Obama apparently plans to make a sizable government commitment. During the campaign, Mr. Obama vowed to spend $50 billion over five years to spur the adoption of electronic health records and said recently that a program to accelerate their use would be part of his stimulus package.

The Marshfield Clinic, a large doctors’ group in Wisconsin, shows that computerized records can indeed improve the quality and efficiency of medicine. Yet the Marshfield experience suggests that the digital record becomes truly useful only when patient information is mined to find patterns and answer questions: What treatments work best for particular categories of patients? What practices or procedures yield the best outcome?

The Marshfield Clinic “understands that it’s a system of improvement that technology makes possible that really matters, and the electronic health record itself is no silver bullet,” said Dr. Carolyn M. Clancy, director of the federal Agency for Healthcare Research and Quality.

For the Obama presidency and the administrations that follow it, the challenge will be to somehow link electronic medical islands into a network that begins to approach on a national scale what organizations like Marshfield have achieved regionally. Ideally, a lone physician in a rural community could tap into the national health information network and be as well informed on treatments and research for patients with certain conditions as a specialist at Marshfield.

Some experts caution that such a broad capacity for record-sharing could take decades to achieve — if it is even possible in the decentralized American marketplace of medical competitors.

Marshfield Clinic, a nonprofit organization founded in 1916, has a long history of using information technology to further research and improve care. In the 1960s, the clinic bought the digital breakthrough of its day — a mainframe computer — and used punched cards to feed it information on diagnoses and procedures. In 1985, the clinic introduced its first basic electronic health records, kept refining them and by 1994 mandated that its doctors all use them. In 2003, it introduced wireless tablet computers, whose screen can written on like digital paper or flipped up, exposing a keyboard, and used as a conventional laptop PC.

Today, Marshfield’s 790 doctors and their support staff at 43 locations in Wisconsin all use the tablet PCs. At the end of last year, the group eliminated paper charts for the more than 365,000 patients its doctors see each year, freeing up storage space the size of a football field at the main clinic in Marshfield. At each step toward a fully digital system, physicians were consulted and involved in the design process.

“It’s been a fabulous journey from physicians being reluctant to now being unable to live without this technology,” observed Dr. Karl J. Ulrich, the clinic’s chief executive. Marshfield is one of a few dozen medical groups across the country that are aggressively embracing information technology. The organizations tend to be big — ranging from providers with thousands of physicians like Kaiser Permanente and the Department of Veterans Affairs to ones with hundreds like Marshfield and Geisinger Health Systems in central Pennsylvania. They are typically responsible for most or all aspects of a patient’s care. They are often insurers, as well.

Those groups, in other words, have the scale and economic incentives to invest in information technology to capture the gains from improved quality and efficiency. In that regard, they lie outside the mainstream of America’s health care economy, a fee-for-service system in which providers are typically paid for doing more, not necessarily doing better. It is a system that encourages more doctor visits, more tests, more surgical procedures, more pills.

For most doctors, who work in small practices, an investment in electronic health records looks simply like a cost for which they will not be reimbursed. That is why policy experts say any government financial incentives to use electronic records — matching grants or other subsidies — should be focused on practices with 10 or fewer doctors, which still account for three-fourths of all doctors in this country. Only about 17 percent of the nation’s physicians are using computerized patient records, according to a government-sponsored survey published in The New England Journal of Medicine.

Even for the large doctor groups, there is no crisp, conclusive cost-benefit arithmetic. Marshfield can point to various measurable savings, but has scant proof they outweigh the millions spent in the past and the $50 million-a-year technology budget.

“People ask about return on investment, but that’s the wrong question,” said Dr. John W. Melski, the medical director of clinical informatics at Marshfield. “This requires the usual leap of faith that knowledge will yield good things — better care, doing things smarter and, yes, saving money in the long run.”

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Friday, January 23, 2009

Little White-Coat Lies |

There are big lies. And little lies. And somewhere in between there are the lies we tell our doctors. Even back in the day, Hippocrates, the father of modern medicine, knew that those pesky Greek patients might tell a fib or two. To find out if they were stretching the truth, Hippocrates measured their pulse rates.

Janie Hoffman's doctor didn't have to do that. During a routine visit, Hoffman's doctor asked her if she was still smoking. Hoffman said, "No, I quit." Her doctor then looked at her and said: "I guess that pack sticking out of your purse is for a friend." Still looking for an out, Hoffman replied: "How did that get there?" It would have been smarter for Hoffman to suffer the embarrassment and 'fess up. It may be painful, but telling your doctor about your questionable health habits like eating vats of junk food, or talking about socially risky behaviors like overindulging in alcohol, illegal drugs or unprotected sex, could save your life.

That's not always obvious to patients who sometimes feel that telling a fib, or omitting information, can be less angst-inducing than listening to a diatribe about the dangers of certain lifestyle choices. "I'm not stupid and everyone knows that smoking is bad, but who wants to hear a lecture?" says Hoffman, a Los Angeles marketing executive who kicked the habit (honestly) not long after that visit and has been tobacco-free for more than five years. Apparently, not too many of us. According to survey done by WebMD, Hoffman is among the 13 percent of 1,500 respondents who actually admitted they lied to their docs. Thirty-two percent only admitted they "stretched the truth," which is a lie by any other name.Our lies cover the gamut. Nearly 40 percent of folks lied about following a doctor's treatment plan, and more than 30 percent lied about their diet and exercise regimens. Folks were also not truthful about smoking, risky sex, alcohol intake, recreational drug use, taking medications as prescribed, second opinions, and the use of alternative therapies and supplements, among other things.

Not telling your doctor about all the health products you're taking, even if they seem innocuous, can be particularly risky. A study that appeared in the Journal of the American Medical Association in December shows that about one in 25 adults between the ages of 57-85 are putting themselves at risk for major drug interactions when mixing prescription drugs, such as a commonly prescribed blood thinner, with over-the-counters like aspirin, vitamins and supplements, such as the popular ginkgo biloba. "Patients have to come clean about the various things they put in their bodies," says Dr. David C. Thomas, associate professor of medicine, at New York's Mount Sinai School of Medicine. "We ask questions for a reason."

Doctors believe that most patients don't walk into their offices intending to lie. But they know that fear of judgment, the desire to appear to be a good patient, a lack of understanding about why certain questions may be asked, and even insurance worries, often lead them down the path of duplicity.

And when it comes to fibs, doctors have heard it all. "The classic is that a lot of patients will underestimate the number of sexual partners they've had," says Dr. Deborah Lindner, an OB/GYN at Northwestern Memorial's Prentice Women's Hospital in Chicago. She concedes that "after a certain number" that particular lie doesn't "really matter that much," but women who deceive themselves and don't practice safe sex, for example, run the risk of sexually transmitted diseases not to mention problems with fertility. "No one wants to admit to risky sex, or having multiple partners, or smoking, or drinking too much," says Lindner. "But people must understand we ask these questions not because we are judging someone, but to keep them healthy."

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Thursday, January 22, 2009 Sick kids: Send them to daycare or keep them home?

It's long been a truism that children's daycare can be a petri dish, full of bugs just waiting to pounce. Now, a body representing Canadian pediatricians is for the first time addressing just how parents, staff and doctors can do more to prevent the spread of infection in licensed care.

"We have to figure out when it's safe for children to be in a child-care facility, when should they be at home and when should they be seeing a physician," says Mia Lang, lead author of a new Canadian Paediatric Society position statement about the prevention of injury and infections in daycare.

One factor contributing to infectious children attending daycare, highlighted in a separate Ontario survey of child-care workers, is that parents can be under pressure not to miss work to stay home with a child. In the survey, 64 per cent of child-care workers say they have felt pressure from parents to care for a sick kid.

The new CPS statement suggests updates to a number of regulations that are in place in licensed daycares.

Among the recommendations:

All child-care centres should have a written policy (in accordance with provincial or territorial health policies) on the management of a sick child, which is reviewed by all staff.

The policy should contain information on recognizing an emergent illness or injury, and on when to call for an ambulance, the proper use of antibiotics and the characteristics of common pediatric infections.

Child-care centres should document the reason why a child is excluded from care.

Children with strep throat or pink eye should have 24 hours of antibiotic therapy before returning to child care.

Children with diarrhea should be excluded if their stool cannot be contained in a diaper, cannot be controlled by a toilet-trained child, or there are signs of fever or blood or mucus in the stool.

Dr. Lang, a pediatrician at the Royal Alexandra Hospital in Edmonton, says the risk of respiratory illnesses is one of her biggest concerns. As daycare use increases in Canada, research suggests that for every nine hours a child is in daycare a week, there is a 12 per cent increase in respiratory illness days.

"It's not unexpected for children who are in a child-care facility to get a cold or upper respiratory tract infection at least once a month," she says, adding that symptoms can last two or three weeks.

If a child has energy, is eating and drinking well and does not have a fever, it's fine for him to be in daycare. But if he's coughing, that infection can spread, Dr. Lang says.

Staff and parents sometimes misinterpret the guidelines and rules in place at daycares.

For instance, a common child-care policy allows a child to come back to daycare after 24 hours on antibiotics, but these policies are recommended for such illnesses as pink eye and strep throat, not for colds or respiratory infections.

The Ontario survey of child-care workers found that 69 per cent said they had accepted a child with an upper respiratory tract infection back into care because they were taking antibiotics - without clarifying the nature of the child's illness.

"That's unfortunate because an antibiotic may not have been the right medication choice," Dr. Lang says.

First, the cause of colds and some respiratory infections are viruses, not bacteria.

In these cases, not only will an antibiotic not make a child well, it will do nothing to stop the spread of infection. Second, the overuse of antibiotics may contribute to antibiotic resistance and side effects such as diarrhea.

The CPS statement also encourages government and businesses to develop more sick-care centres, or even "sick rooms" in current centres, staffed by health-care workers, both to keep sick kids away from others and to reduce worker absenteeism.

Sandra Cuming founded a private Toronto service that provides sick care inside the home. Without any backup such as hers, parents may resort to filling kids up with Tylenol and Gravol to mask symptoms and pack them off to daycare, she says.

"And then they don't answer their phone," she says. "They're that panicked. They're between a rock and a hard place."

Last Friday, Hamilton mom Tobi Bruce stayed home with her four-year-old son, who had diarrhea. Although he seemed on the mend, she decided to obey the centre's rule disallowing children with a bout of diarrhea in the last 24 hours.

"Your first instinct is to say, 'They'll never know he was sick,' " she says.

But yesterday, she sent her one-year-old to his new daycare with a cold because he had no fever or diarrhea. If his cold gets worse, she or her partner will stay home with him.

"Even though your instinct is to try to get them in for the day, you wouldn't want another parent to do that," she says.