Several readers shared this link about a smartphone app that tracks patient activity and reports it to physicians. Called Ginger.io, the app is being studied at several hospitals in the US. The goal is to mine data on phone use and movement to show changes in patterns that could indicate illness or worsening of chronic conditions.
The app has to be activated by a hospital or health care company and obtains a baseline on personal activities once it’s activated. Caregivers are notified when there are changes in patterns of travel, phone calls, texting, etc. According to the Ginger.io website, it uses both passive data collected from the phone and active data reported by patients to create context-sensitive interventions.
The behavioral analytics platform is based on research from the MIT Media Lab. Several interesting papers are referenced on the website. With the level of data that can be gathered, privacy is a concern. The site claims to “only collect data we need to paint a rough texture of your behavior.” Patients are able to control whether data is shared with clinicians and researchers and can opt out at any time.
As a primary care physician I find the idea intriguing. The key is in the predictive ability of the algorithms to identify when a patient would benefit from an intervention. For this to really take off with hospitals and health systems, however, outcomes are not enough. It’s going to have to demonstrate cost savings as well. It will also take some patient education to make some of the “insights” valuable. Just looking at the screenshot, they’re pretty vague. “On Wednesday, you spoke with 2 fewer people than average.” “You interacted with 22% more people than average on Thursday.”
It reminds me of a virtual parent of high school students. You need to get out more. Stop talking on the phone and go to bed. You’re spending longer on your homework than usual. Get some exercise. You’re texting too much. Your music is too loud. There are twice as many miles on the car as there should be for where you said you were going.
Thinking back to what my phone has been up to the last several days, I wonder what the app and related algorithms would think of me. My boss is out of town, so I used Monday and Tuesday as rare opportunities to work remotely. I love working from home – I’m at least 40 percent more productive than in the office and feel a greater sense of accomplishment. I was able to use my land line and wasn’t running around so I made virtually no calls. Would it think I was withdrawn? Or would it interpret the flurry of text messages as I tried to reschedule a girls’ night out as evidence that my behavior was still within the range of normal?
Have you tried Ginger.io or do you know anyone who has? I’d love to hear what they have to say about it. E=mail me.
MMR Global has filed a patent infringement suit against Allscripts’ recently acquired subsidiary Jardogs. The suit references Jardog’s FollowMyHealth patient portal as infringing on an MMR Global patent. Prior to this suit, MMR Global had been predominantly targeting hospitals and health systems in its string of lawsuits, but it appears that patient portal vendors will now be targeted as well.
Organizations from California, Massachusetts, Minnesota, and Wisconsin have announced the formation of a new collaborative initiative with the goal of documenting and sharing best practices guidance to help hospitals prepare for ICD-10 conversion.
Louisiana State University and Siemens Healthcare have informed 8,000 patients that their personal health information was exposed after a bug in Siemen’s system associated visit information with incorrect billing addresses. Siemens had been contracted to print and mail patient bills on behalf of LSU. The issue was discovered when patients began calling the hospital reporting incorrect names and treatments on their bills. No social security numbers, birthdays, or account numbers were exposed in the breach.
National Coordinator for Health Information Technology Farzad Mostashari, MD, will deliver the opening keynote speech during the ICD-10 Forum on June 17-18.
IDC Health Insights has published a guide to ACO formation, detailing five stages of what it calls ACO maturity. The report emphasizes the importance of introducing new technologies, like data analytics and mHealth apps to support post-acute care, only once key maturity levels are reached.
The news just came out the Mitochon is shutting down their Free EHR service. They aren’t closing as a company (more details below), but they will no longer be offering EHR software. Here’s the full shutdown message:
Effective mid June 2013, Mitochon intends to exit the EHR market and cease our physician service.
We are sensitive that our providers’ medical practices will be affected by this. However this difficult decision has been driven by the need to focus on other lines of business, and the increasing liabilities we are incurring while supporting our free EHR service.
We will keep our active subscribers updated in the coming days as to how we will address the important issue of clinical data retrieval as well as possible alternate systems and solutions we are in discussion with.
It is with a heavy heart that we are existing the EHR market. The Mitochon team appreciates the support all of our clients have shown to us over the past few years and will work diligently to ensure this transition will be as smooth as possible for their practices.
Dr. Andre Vovan & Mr. Chris Riley
Mitochon has been a great supporter of EMR and HIPAA over the years, and so I’m sorry that Dr. Vovan won’t be able to see his vision come to fruition with the Mitochon EHR. He was one of the first people I met who was talking about a community based approach to caring for patients. It’s interesting to see many of the topics he told me years ago are being talked about so much now in the world of ACOs.
As for the Mitochon EHR software, I won’t be surprised if some other players in the EHR space decide to take over the code and EHR business from Mitochon. There are actually a number of companies that have been white labeling the Mitochon EHR and it won’t surprise me if one of those companies takes over the codebase and users.
What’s likely more interesting is where Mitochon plans to take the company. Ever since I first met Mitochon years ago, their goal had been to build their own ad network and supply other third party networks. Now their focus will be exclusively on their content delivery and advertising network business. As Chris Riley, CEO, mentioned to me in an email, being in the EMR business and trying to partner with EMR vendors can often be a big issue.
Mitochon has some patents around CPT and ICD level targeting of ads. So, it will be interesting to see if Mitochon can become the pharma ad network for EMR companies. Although, there are a lot of non EMR opportunities for Pharma advertising as well. It will be interesting to see where Mitochon takes the company going forward.
Portuguese and Spanish researchers in the field of social robotics are working on the use of robots to interact with children who are hospitalized for the treatment of cancer, thereby providing emotional support.
The researchers are keen to take robots out of the laboratory and place them in a real environment. Until now, most of the research on social robotics has taken place in very controlled environments. As Professor Salichs from UC3M points out, 'The introduction of a group of autonomous social robots into surroundings with these characteristics is something new, and we hope that the project will help us to advance in the development of robots that are able to relate to people in complex situations and scenarios.'
Another cause for guarded optimism about health care robotics? My hope is that it will augment the efforts of often overworked staff and allow them to better prioritize the focus of their precious attention and energy. In addition to their potential social value, robots could act as in situ surveillance devices to watch for nascent or emergent health crises. My fear is that they will be used as justification for cutting costs through staff reductions, as self-checkout lanes have done in supermarkets.
There is a correlation between having a pet such as a dog or cat and an improved health status. Exactly how this works was the subject of a recent article (See: American Heart Association: Pets, especially dogs, are good for the heart). Below is an excerpt from it:
An animal companion may not just warm your heart, but also help you maintain a healthy heart....Pet ownership, particularly dog ownership, is probably associated with a decreased risk of heart disease," [said the] director of the cardiac care unit at Baylor College of Medicine....[T]here are 78.2 million owned dogs and 86.4 million owned cats in the United States. Thirty-nine percent of U.S. households have at least one dog, while 33 percent have at least one a cat. The AHA's committee reviewed previous research on how pets affect human health, and they found studies that showed owning a pet was associated with fewer heart disease risk factors and increased survival among patients. In particular, owning a dog was shown to reduce cardiovascular risk, perhaps because dog owners are more likely to engage in physical activities just by walking them. One study of over 5,200 adults showed that dog owners were more active than non-dog owners, and were 54 percent more likely to reach recommended levels of physical activity....[A cardiologist said that] "there are plausible psychological, sociological and physiological reasons to believe that pet ownership might actually have a causal role in decreasing cardiovascular risk." [He also] pointed out though if people buy a pet but sit around all day, smoke, eat whatever they want and don't monitor their blood pressure, heart benefits aren't likely."
So walking your dog improves one's health by providing an incentive to walk him around the block a few times a day. This probably won't help if the owner engages in other unhealthy habits. You all know what they are. I also believe that caring for a pet has unique psychological benefits such as relieving stress. These benefits have been shown to be more effective than ACE inhibitors in lowering blood pressure (see: Pet Dog or Cat Controls Blood Pressure Better than ACE Inhibitor):
[A professor of medicine] assessed the effect of social support on heart rate, blood pressure and renin reactivity in response to mental stress in a group of 48 stockbrokers, all of whom were being treated with lisinopril, an angiotensin converting enzyme (ACE) inhibitor used to treat hypertension. She found that in 24 participants selected at random to add a dog or cat to their treatment regimen, these cardiovascular measures remained significantly more stable during stressful situations than in 24 participants in the non-pet-owner group, who served as controls.
The bottom line is that rather than spending money on drugs and surgery for yourself, redirect it to the veterinary bills for your dog and cat. It's a better investment.
On June 7th, 2013 the Texas Children’s Hospital and Smith Seckman Reid are producing an educational workshop on medical device connectivity. Nursing is the predominate perspective explored in this event. (One of my pet peeves is all the focus physicians get from vendor’s marketing departments. Yet, when it comes to systems in hospitals, the predominate user – by far – is nursing.)
TCH, an early adopter of clinical documentation into EMRs and alarm notification, has some of the most extensive experience with medical device connectivity in the US. They’re hosting and presenting at this one day seminar. Here’s the blurb on the event, with links to where you can register. Besides the great content, the next best thing is the cost – free. The only downside is there’s room for just 150 attendees.
The context for this even is the planning, implementation and opening of a new building at TCH. This was a maj0r new building with both ambulatory and inpatient facilities, and lots of new technology and systems. Besides expanding the physical plant, TCH was looking to improve patient care and outcomes.
The day opens with a focus on workflow and assessing needs. TCH delves into their vision of technology in the service of improved workflow and past experience about the system’s they’ve implemented. Next, myself, Debbie Gregory and Joyce Sensmeier will be on a panel discussing the issues from an industry perspective. In the afternoon, TCH presents “executing the vision,” and their experience with the opportunities and challenges of the new systems and how they impacted operations in their new building.
Should be a terrific event.
Cisco Systems is running this commercial about the “Internet of everything,” with a focus on connected healthcare.
It all sounds great, but how much of this is grounded in the real world today and how much is wishful thinking? I mean, connected medical records? It sounds so idealistic.
More Time Spent Selecting the Right EMR Vendor is a Prudent Investment ow.ly/kRPvC
— Billy Cline (@RecruiterBillyC) May 20, 2013
A prudent investment is an understatement. The very best use of your time in an EMR implementation is in the selection process. Although, I’ve also seen some clinics go too far and run into the issue called “paradox of choice.”
— Jonathan Govette (@ReferralMD) May 19, 2013
Mobile EMR has always been a wonderful idea, but how many are really using their EMR on a mobile device. Let’s also not confuse mobile EMR with remote EMR. Certainly many doctors are using the same EMR from multiple clinics. That’s common and beautiful. However, far fewer are using their EMR on a mobile device. The most common response I get from doctors about a mobile EMR is “I can access my EMR on a mobile device, but the experience is terrible.” I expect this will dramatically change over the next 3-5 years, but won’t likely be the full EMR. Instead, I think it will be a really focused set of EMR functions on the mobile device. I’m not sure anyone has nailed that experience yet. Although, a lot of EMR vendors are working on it.
— Dr. Vicki Roberts (@fmsemo) May 19, 2013
Everyone that’s read this site for a while knows how much I love analogies. Both of these are pretty spot on. The root canal is necessary and can relieve a lot of long term pain, but it’s no fun going through the process. Buying a car is hard because there are so many choices and so many details that it’s hard to know what really differentiates the complex item you want to buy.
Free web-based ambulatory EHR vendor Mitochon Systems has announced that it will close its health IT business unit. Mitochon was a Meaningful Use Stage I certified vendor with 12 attestations according to the most recently released CMS data.
Seattle-based Tableau, a data visualization vendor popular in the healthcare space, raises $254 million on its IPO Friday and shares closed up 64 percent at the close of its first day of trading.
Wake Forest Baptist CIO Sheila Sanders will step down from her position effective May 31st. She leaves her position for personal reasons, unrelated to recent difficulties with Baptist’s Epic implementation.
MD Anderson announces a wage freeze, a reduction in hiring, and the postponement of construction projects due to lower than anticipated operating income for FY13. President Robert DePinho reports that an increase in donations and investment income is the only reason the institution will finish the year with positive net income.
From The PACS Designer: “Re: Microsoft’s updated BAA. Microsoft has released an update for its Business Associate Agreement to encompass more secure communications tools for HIPAA compliance. The changes provide for healthcare organizations to leverage cloud solutions to improve clinician productivity, care team communication, and care transition coordination while maintaining compliance with the recently updated Omnibus HIPAA Final Rules.”
From Laboratorian: “Re: University of Michigan. Goes live June 1 with a massive IT rollout. This includes a new Epic (Denali) implementation and a completely new LIS, an experimental version of SCC-Soft being used at U-M for the first time. The LIS rollout, in particular, is particularly audacious in scope, being the culmination of a seven-year implementation cycle. Barcode-based tracking of both tubes and surgical pathology specimens will be on par with the level of automation seen at BML labs in Japan. The spatial location of every asset in lab space will be tracked in real time. The project benefitted from co-development of code with support from U-M’s own software engineering teams. Nearly 2.5 million lines of new code above base SCC product will drive this new version.” SCC is often forgotten as maybe the leading LIS vendor for big health systems, and writing 2.5 million lines of new code is just crazy. Obviously Beaker wasn’t going to do the job for UM, although it’s improving to the point that some larger Epic customers are cautiously committing to it.
More than two-thirds of respondents think that Meaningful Use Stage 2 should be extended for a year before starting Stage 3. New poll to your right: CMS released hospital Medicare pricing information for the top 100 DRGs. How valuable is that information to the public?
Jamie Stockton of Wells Fargo Advisors sent over his monthly summary of hospital EHR attestations by vendor. Customers of the big multi-national corporations whose business is mostly not healthcare IT (McKesson, Siemens, and GE) are the clear laggards.
Just in case you are wondering what it would be like to have HIMSS darling and cardiologist Eric Topol, MD as your doctor, ponder this quote from an NBC fluff piece from January that I just ran across: “These days I’m actually prescribing a lot more apps than I am medications.” He claims that up to 80 percent of the 20 million echocardiograms performed each year could be replaced by in-office smart phone tests, saving the healthcare system $13 billion per year. In a stunning piece of investigative journalism, the on-camera talking head (also a doctor) who has clearly performed her research convinces him to eat tortilla chips and goads him into saying positive things about his own books and devices.
EHR vendor Mitochon Systems notifies its customers that it will shut down its free cloud-based EHR service in mid-June. The company isn’t sure how doctors will retrieve the data they’ve entered on patients before the system is turned off, but says it will come up with something.
Data visualization software vendor Tableau Software, whose product is popular in healthcare, raised $254 million in its Friday IPO as shares soared 64 percent. I’ve played around with it a couple of times and it’s pretty cool – there’s a free trial download on the site.
Sheila Sanders, VP/CIO of Wake Forest Baptist Medical Center (NC), will step down effective May 31. The hospital says she’s leaving the $465K job for personal reasons that are unrelated to its struggles with Epic.
CareWire names advisors Ken Saitow and Phil Hotchkiss as president/CEO and EVP/chief product officer, respectively.
Encore Health Resources CEO Dana Sellers was recognized Friday, May 17 as a Distinguished Engineering Alumna by the Cockrell School of Engineering at The University of Texas at Austin. She was also named Friday as a finalist for the Ernst & Young Entrepreneur of the Year for the second consecutive year.
James Holtzman is promoted from CFO to CEO of Prognosis Health Information Systems.
Terry Boch (JET Health Solutions) joins Wellcentive as SVP of sales and marketing.
Susan K. Newbold PhD, RN-BC, director of Nursing Informatics Boot Camp, is selected as one of the 2013 “Women to Watch” by the Nashville Medical News.
MD Anderson, which just announced Epic as vendor of choice, will freeze wages, cut back on hiring, and postpone construction projects, hoping to offset an anticipated 2014 financial shortfall that it blames on the federal government (the Affordable Care Act, the budget sequester, and federal deficits) even though its rapidly increasing operating expenses seem to be its primary problem.
A controversial decision by Britain’s NHS allows life sciences and insurance companies to buy access NHS’s patient-identifiable data (“bespoke patient-level abstracts), even providing companies with an Excel worksheet to calculate their cost.
Partners HealthCare System (MA) made a $133 million profit in the latest quarter even after it took a $110 million accounting charge to write off computer systems slated for replacement. Most of that came from investment income, as operating income dropped from $41 million last year to $5 million.
Vince covers Part 1 of the HIS-tory of Allscripts this week (more specifically, TDS, which passed through many hands before landing in the Allscripts lap via its acquisition of Eclipsys.) Vince also scored a major coup for upcoming episodes – he e-mailed Judy Faulkner at Epic and asked if could talk with her about the company and she invited him to meet with her in Verona, which he did last week and is still gushing about. Those are going to be some great HIS-tory installments.
256 Shades of Grey(scale): The Dirty Little Secrets of Radiology and PACS
By Brad Levin
There is widespread agreement that radiology has been the epitome of success spreading PACS far and wide over the last two decades. Thousands of organizations transformed from the dark ages of film to digital operations. Early activity started in the mid-1990s and peaked in the mid-2000s. Once the 2000s were in full swing, many groups moved to PACS for the first time, but it was relatively common for PACS early adopters to have implemented their second or in rare cases, their third PACS by then.
Along came the late 2000s, when industry analysts KLAS and Frost & Sullivan called for the next wave of PACS replacements. Many systems had aged well beyond the average 5-7 year lifespan of PACS, and it seemed like a solid market forecast. However, in reality the replacements never came in earnest.
Fast forward to present day and the institutional use of PACS has stagnated. PACS continue to be used past their useful life, problems persist, and upgrades are delayed. The other contributing factor is a majority of institutions today are using PACS born in the late 1990s or early 2000s. Their vendors purchased PACS largely through acquisition, and while these systems have been upgraded periodically, most of the core architectures remain largely unchanged.
This would be fine if time stood still, but of course it hasn’t. Over the last two decades, modalities have advanced at breakneck speed, producing computed/digital radiography, multislice CT, PET/CT, digital mammography, and the newest modality, digital breast tomosynthesis (or 3D mammography).
Modern technology has also dramatically changed consumer and physician expectations. Everyone expects instant gratification. Pay phones are extinct and we all use smartphones. The world is app-driven and tablet accessible. LPs/CDs have been replaced with MP3s. Medicine is mobile, and we’ve ditched our VCRs/DVDs for streaming media.
Today’s challenging healthcare environment, supported by yesterday’s PACS technology, has led to widespread chronic problems and missed opportunities. When I was told recently that some of the most senior leaders in imaging informatics had convened and were discussing how "Radiology Has Solved The Problems of Going Digital", I was stunned. Based on what I see at community hospitals, academic medical centers, IDNs, imaging centers, radiology groups, and teleradiology vendors, I know that statement couldn’t be farther from the truth.
The vast majority of practices are digital, but are their problems solved? In my view, absolutely not. Just this week I spoke with a PACS administrator from a 400-bed hospital in the Southwest. I was told that when their network access peaks, performance gets crushed on PACS, taking up to a minute to launch even a small CR study. Radiologists launch the study on PACS, grab a coffee, and hope that when they come back they can start reading the study. While this may or may not be just a PACS issue, it is a persistent, unacceptable problem nonetheless.
If you are unaware of the state of your imaging operations, I encourage you to speak to your radiologists, referring physicians, PACS administrators, and your IT staff. You may also consider meeting with your affiliates, and plan on attending the upcoming SIIM 2013. If you tackle today’s Imaging problems with the same vigor you used to transform from film to digital, your problems will quickly go into the rearview mirror.
Brad Levin is general manager, North America for Visage Imaging.
Have you considered what an EMR would look and feel like if it integrated telemedicine? Rashid Bashshur, director of telemedicine at the University of Michigan Health System, has given the idea a lot of thought.
In an interview with InformationWeek Healthcare, Bashshur tells IW’s Ken Terry that it’s critical to integrate HIEs, ACOs, Meaningful Use and electronic health records.
Makes sense in theory. How would it work?
To begin with, Bashshur said, healthcare providers who have virtual encounters with patients via a telehealth set-up should create an electronic health record for that patient. The record could then be ported over to the patient’s PHR. The physician can also share the health record via an HIE with other providers.
When providers attempt mobile and home monitoring, it steps the complexity up a notch, as such activities generate a large flow of data. The key, in this situation, is to use the EMR to sensitively filter incoming data.
Unfortunately, few EMRs today can easily pinpoint the information providers need to process, so most organizations have nurse care managers sift through incoming monitoring data. That’s the case at University of Michigan Health System, where care managers sift data manually to determine whether patients seem to be seeing changes in their conditions.
Unfortunately, even attentive care managers can’t catch everything a properly-designed system can, Bashshur notes. To integrate EMRs and telemedicine/remote monitoring, it will be important for EMRs to have sophisticated filters in place which can pinpoint trouble spots in a patient’s condition, using a standard protocol which is applied uniformly.
According to InformationWeek, vendor eClinicalWorks has promised a new feature which can pick out relevant data from a large data stream. But until eCW or another EMR vendor produces such a feature, it seems that remote monitoring will be labor-intensive and expensive.
Judith Faulkner, founder and CEO of Epic, is warming up to the media according to an interview in Forbes by Zina Moukheiber (see: An Interview With The Most Powerful Woman In Health Care). Here's the reason that she offers in the interview:
I’m recognizing that when we were small, we could stay under the radar, but now it’s harder. I get so many requests for interviews. If I talk to everyone, we can’t do our job with our customers and work on our software. It would be hard to stay focused.
Here's one of the many reactions to the piece by David Shaywitz, also of Forbes (see: Two Quick Reactions To Epic Faulkner Interview: SV Should Show Judy More Love; We Should Shouldn't Let Hospitals Off Hook)
Interoperability issues associated with Epic may reflect tacit preferences of hospital systems. Tory Wolff and I have discussed the interoperability challenges associated with Epic, and it’s potentially negative impact on the innovation ecosystem (see here and here). Faukner’s comments don’t particular assuage my concerns, but certainly highlight Epic’s laser-focus on delivering what customers want – and make no mistake, the customer isn’t the patient but the hospital. This is critical to appreciate. Thus, while it’s easy (and appropriate) to critique Epic for impeding data sharing, it’s probably also important to remember that if hospitals were all that keen to share data better, I suspect Epic would rapidly find a way to accomplish this. It’s almost as if Epic provides hospitals with plausible deniability. While it may be convenient to blame EMRs in general, and Epic in particular, for data access challenges, I suspect we also need to dig deeper, and hold hospital systems themselves far more – what’s the word? – accountable.
I couldn't agree with Shaywitz more. In fact, here's a quote from my note of September 14, 2011 (see: Judith Faulkner, EMR Interoperability, and Washington IT Politics)
Now comes a little secret that is not discussed much. Hospital CEOs and CIOs have little interest or enthusiasm for multivendor interoperability, either within their hospitals or hospital systems or across the outside hospital systems that they compete with. Customized interfaces between heterogeneous systems are a pain in the rear-end for the CIOs. They would thus rather have shrink-wrapped integration delivered by a vendor like Epic, the so-called "enterprise solution." Moreover, CEOs don't want to encourage broad patient and clinical data portability because it gives the payers (insurance companies and the federal government) a strategic advantage during negotiations about reimbursement.
So, when the feds raise the topic of interoperable EMR software, most hospital CEOs and CIOs will stand up and cheer. However, when they go out to purchase EMR software, they largely select Epic, particularly the larger ones that can afford it. Faulkner provides the non-interoperable product that they really want. She can also runs political interference for them. She donates generously to the Democratic party, she is tight with the Wisconsin congressional delegation, and takes no prisoners in her political feuds (see: Epic Flexes Its Political Muscle in Wisconsin with Boycott). And she can now try to block any inconvenient initiatives in the arise in the Health Information Technology Policy Committee.
Epic will provide some measure of interoperability to her hospital clients but slowly and most efficiently among Epic client hospitals. This is what her hospital clients want and this is what she will give to them. Here are the (slightly garbled) Epic "rules of the road" in terms of working with other HIT vendors, quoted from the Forbes interview:
We don’t let anyone write on top of our platform, come read our code and study our software. I worry about intellectual property at that point. With our customers, we make sure we have signed agreements. They know they have to respect our software. Customers can do it in a controlled environment, but not the whole world. You’ll see us do more and more of that.
I now present the latest health IT-related podcast from Sivad Business Solutions, an interview with Suzanne Leveille, research director of OpenNotes, a project to give patients online access to the entirety of their own medical records, including the visit notes from clinicians. Leveille describes a trial at Beth Israel Deaconess Medical Center, Geisinger Health System in Pennsylvania and Harborview Medical Center in Seattle. She reported that not one of the 105 participating physicians asked for the access to be shut off after a year. In some cases, patients even discovered errors and prevented adverse events.
Here is the description from Sivad:
A pleasure to welcome Suzanne Leveille to the program today. Suzanne is a professor of nursing at The University of Massachusetts-Boston, and the research director for OpenNotes.
OpenNotes is an initiative that invites patients to review their visit notes written by their doctors, nurses, or other clinicians.
As a patient, you have the right to read the notes your doctor or clinician writes about you during or after your appointment. Having the chance to read and discuss them with your doctor or family member can help you take better control of your health and health care.
As a healthcare professional, you may build better relationships with your patients and take better care of them when you share your visit notes. Our evidence suggests that opening up visit notes to patients may make care more efficient, improve communication, and most importantly may help patients become more actively involved with their health and health care.
Some highlights from the conversation include: the dramatic improvement between patient and doctor communications; how they overcome potential push back and resistance from physicians; patients became more engaged in their personal health care; OpenNotes has been pleasantly surprised at the patient engagement; how advanced technologies and mobile technology are going to impact the future of this idea; and how they are planning to spread the word and get more patients and doctors improving communications and care with OpenNotes!
I recently learned about the concept of a lab formulary, an analogue of the pharmacy formulary. The latter is a list of the stock drugs carried by the pharmacy in a hospital. Prescriptions for hospital patients can only be written by physicicans for the drugs listed in the formulary. The comparable notion on the lab side is that only tests contained in the lab formulary can be ordered by physicians. Here is an article that describes the concept in greater detail (see: Constructing A Lab Formulary). Below is an excerpt from it:
Given healthcare's increasing emphasis on cost control and quality measurement, laboratorians need to reconsider their roles within healthcare organizations. A lab that provides what appears to be a commodity service may be at risk of being marginalized at best or outsourced at worst. But a laboratory that plays a highly visible role in promoting high-quality clinical care can strengthen its status within a hospital or healthcare system. One approach worth considering is to think of the laboratory test menu as a "laboratory formulary" analogous to the drug formulary maintained by a hospital pharmacy. Despite what outsiders might think, the role of the hospital pharmacy goes far beyond simply stocking drugs and fulfilling orders. For one thing, it is not feasible to stock every drug in every formulation that a physician might order. For another, it would not be in patients' best interests for pharmacists to fulfill blindly all orders they receive.
...[T]he appropriate role of the laboratory professional goes far beyond simply maintaining analytic quality and fulfilling laboratory orders. It includes determining what test methodologies will be offered and in what forms, specifically point of care, in-house laboratory and referral laboratory. It also includes redirecting physicians when they order tests that the laboratory knows to be suboptimal....The stereotype of a lab professional, whether technologist, clinical lab scientist or pathologist, is one of an introvert who likes to hide away in the lab... But the stereotype still risks being self-fulfilling....As lab professionals find creative ways...to share diagnostic testing expertise with medical staffs, we, too, will see an increase in professional status. And more importantly, patients will benefit through more efficient and accurate diagnostic testing.
I have not heard any strident calls for the use of a lab formulary so perhaps I am stirring up controversy where none exists. One of the major drivers for the development of pharmacy formularies has been the need to switch physicians to the less expensive generic drugs to contain drug costs. If a particular generic drug is the only option available in a hospital, this goal can be more rapidly achieved. The ire prompted by such a shift from the clinicians is transferred from the pharmacist to the hospital pharmacy committee that maintains the formulary. Since there is no "generic equivalent" to lab tests, such a goal can't be used as an incentive for the development of a lab formulary.
I can envision that one major rationale for the development of a lab formulary: the desire to place some limits on the inappropriate ordering of expensive molecular and genomic tests. However, even the most expensive of these tests may be appropriate under the right circumstances. Rather than a blanket ban on such tests, it would seem more appropriate to publish the clinical criteria for the ordering of such tests and then require the approval of a pathologist when these clinical criteria are not met. In other words, publishing criteria for ordering expensive lab tests, and then enforcing them, would be a suitable substitute for a lab formulary.
The patient portal is becoming a really hot topic in healthcare. I think we can attribute much of the discussion to the EMR meaningful use requirements to engage with patients in a patient portal. I recently started a thread on LinkedIn based on a post by Jennifer Dennard called Opening up the Pandora’s Box of Patient Portals. The conversation in the thread was great, but David Voran, MD provided some incredibly valuable insight that I wanted to share with all of my readers. The following are Dr. Voran’s comments based on his experience using a patient portal.
Long have exploited the portal in our organization and we’ve now progressed to where the entire chart is available to patients. Can begin to list the results but here are my counter intuitive findings:
1) The more barriers a clinician erects between them and the patient the MORE work they wind up doing.
- Those of us physicians who have configured the portal to have most message types routed directly to the physician wind up answering less messages at the end of the day.
- Typically physicians will have all medication refill requests, questions about the last visit, requests for visits, etc. routed to a nurse or a pool to attempt to answer first. The majority of the time the person receiving this message can answer only part of the question and will then send a message to a physician for direction; the physician responds and then the nurse will interact with the patient; then the physician has to approve any orders or actions taken. This usually involves having the physician receive or respond in some way to 2 messages in their inbox. Those of us who receive the patient’s message directly answer one.
- Many other examples but typically those physicians who have barriers are answering or responding to 35-50% more messages than those who have no barriers.
2) The more the patient has access to the more engaged they will be and the more accurate the record will be. The patient is the best auditor of the record and will point out inconsistencies that can be corrected.
3) If the physician is the one to enroll or engage the patient. Those physicians who promote the portal will get 60-75% utilization of the portal. Those that are passive will see about 30% response rate.
4) Aggressive use of the portal will eliminate up to 8 hours of patient related phone conversations per nurse per week.
I posted a note five days ago about how the cost of healthcare seems to be gradually declining (see: Decrease in Healthcare Costs May Persist as Economy Revives). A reader, Ajit Alles, responded with a comment that decreasing expenditures of health my result in a lower quality of care, which I responded to in another note (see: The Correlation between the Cost of Care and the Health of a Population). He has responded to this second note with the following comment:
As follow-up, I agree that we spend way too much on end of life care, but that won't be reduced without a cultural shift. People expect miracles from medicine based on what they hear on the news and see in TV dramas. We could spend less and get better results, but people have to first start accepting that modern healthcare has limitations, not the least of which is funding. The new push for genomic healthcare is a good example of unrealistic ideas being pushed for profit. If everyone thinks that they are going to get personalized gene targeted healthcare they are dreaming! I know I'm a curmudgeon in this regard, but we first need to have good basic healthcare before we get cadillac genomics....We in for-profit medicine must share the blame for pushing "new and improved" medicine that is unaffordable and only (marginally) benefits the few people who can afford it. I recently heard of a family that wants some genomic test done on their child with cancer. The test looks at sequence variation in multiple genes and provides a "report" of very limited utility since most of the variations have no specific treatment. The test costs about $25000 and is not covered by insurance ....The family can afford to pay for this so it's being done with the encouragement of the oncologist. There are others who peddle proteomics reports to desperate patients. Enough said. This is the road to ruin.
I would like to respond specifically to his suggestion that "[those of us] in for-profit medicine must share the blame for pushing new and improved medicine that is unaffordable and only (marginally) benefits the few people who can afford it." I agree that many providers participate in "for-profit" medicine. However, the nature of the healthcare enterprise is now changing to what has been called "Big Medicine" or "Big Med" (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; The Transition to "Big Med": Need for Emphasis on Standardization and Cost; Health Systems Use Their Regional Dominance to Muscle Insurance Companies). With the rapid decline of private physician practices, many of the key decisions about the future of healthcare will be made by the federal government, large hospital systems, health insurance companies, and Big Pharma. So while we indeed have a for-profit health system in this country, most of the resources will flow from institutions like the federal government and health insurance companies to large institutions like large hospital systems. The great majority of physicians will be hospital employees. I refer to this as the institutionalization of healthcare delivery. We need to better understand the consequences of this shift.
I think that this change will have a major effect on the incentives experienced by physicians. In previous notes, I have made the point that cancer patients receive better care if the treating oncologist is salaried and does not benefit directly from selecting the most expensive treatment. This idea becomes apparent, as one example, in the treatment of ovarian cancer patients where a private oncologist is incentivised to maximize revenue from patient "chair time" whereas salaried academic oncologists seem to be more inclined in select the preferable intraperitoneal infusion of chemotherapeutic agents (see: Patients with a Cancer Should Seek Treatment in Cancer Hospitals). This is the best therapy but complicated and with lengthy patient visits. Here's are a couple of additional articles about how oncologists are compensated for additional reading (see: Will the Sequester Cause Oncologists to Lose Money Prescribing Chemotherapy?; Who Pays Your Oncologist?).
For private oncologists, the so called "oncology concession" goes to their group practice and they themselves directly benefit financially from their clinical decisions (see: The Oncology Concession Under Attack by Health Insurance Companies). For a salaried oncologist, the "oncology concession" goes to the hospital whose executives may choose to pay their oncologists the internist market salary, retaining the difference. The hospital may then choose to reward its executives at a higher level for developing a bigger cancer center (see: Cancer Business Highly Remunerative for Sloan-Kettering Executives).
I believe that health system executives will be more highly compensated and physicians will be less so as a result of institutionalization. After all, it is the executives who are making macro compensation decision and it would be natural for them to reward themselves. Moreover, these same executives will also have critical decision-making power in terms of how "new and improved" medicine is delivered. I believe that most of decisions will be based on how such care is compensated by the various institutional payers.
Robot Aids in Therapy for Autistic Children
Wall Street Journal (05/01/13) Shirley S. Wang
University of Notre Dame researchers will present study findings at the annual conference of the International Society for Autism Research showing promise in the use of robots for teaching social skills to autistic children. The study, involving 19 autistic children, is believed to be the largest trial to date using robots in this way. The children interacted with a two-foot-tall robot therapist that was programmed to ask novel questions and engage children in conversation. The study participants showed greater conversational improvement with the robot than with a human therapist alone, and parents reported more significant improvement at home as well. Children interacted in six sessions with the robot as well as with a human therapist, who provided instruction on specific skills when interacting with the robot, such as making eye contact or taking turns talking. Simplified social interactions with a robot might be beneficial to children with autism, who tend to be very interested in technology but find complex social interactions challenging. The researchers hope the children will carry over the social skills to interactions with people as well, rather than just interacting with the robot.
Monday's ACM TechNews produced this very brief but tantalizing summary of a Wall Street Journal article.
This is one of those stories that leave me very ambivalent. In some ways, my automatic reaction to our collective desire to depend more on automation in direct patient care is fear. I am afraid we are going to abandon our elderly and otherwise hopelessly disabled kin to the unfeeling arms of robots, androids, whatever. This will spare us the feelings aroused by an out-of-control psychotic spouse, an incontinent and demented parent, or a profoundly developmentally disabled child, when we must intervene and our interventions are resisted, not appreciated, or insufficiently effective.
With this story, I see the situation is not so simple. Autistic children have difficulty relating to humans with whom they are intimately involved, and their difficulties are often reflected in others' responses to them. Machines are insensitive by nature, and can be programmed to reward positive behavior and ignore the negatives. This may be a situation, as the investigators assert, where robotic intervention is not only appropriate as an alternative but can even improve the patient's situation holistically.
I don't have a WSJ subscription so I can't follow the link ACM provides to the full story, and I don't have time at the moment to poke around on the Web for alternate sources of information about this research project. I would like to learn more, and will try to pursue this when I have more time.