Monday, April 16, 2012


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Saturday, April 7, 2012

Accountable Care Organizations Could Bring Necessary Changes to Health Care

According to a report issued by the Centers for Medicare and Medicaid Services (CMS), in 2011, beneficiaries with multiple chronic conditions accounted for 93% of Medicare fee-for-service expenditures. That means that two out of three Americans over the age of 65 have multiple chronic conditions. Most of these patients see multiple doctors. Too often,their experience is fragmented, resulting in disconnected care where their health records are not available at the point of care; where they undergo unnecessary duplicate medical procedures; and are constantly asked to fill out the same forms at a new doctor’s office when their information is already located in their digital health record that should be available.

Continuity of care is essential to all patients, especially those with chronic conditions. It is rooted in long-term patient-physician partnerships in which the physician knows the patient’s history from experience and can integrate new information and decisions from a whole-patient perspective. The question is whether or not Accountable Care Organizations (ACOs)  can provide that continuity?

Accountable Care Organizations,(ACOs) are part of the proposed new rules included in the Affordable Care Act,signed into law by President Obama on March 21,2010. The ACO is a network of doctors and hospitals that share responsibility for providing coordinated care to Medicare patients. ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. Under the proposed ACO rules, the Medicare Shared Savings Program rewards ACOs that lower escalating health care costs, while meeting performance standards on quality of care, and putting patients first. By focusing on the needs of patients and linking payments to outcomes, these delivery system reforms should improve the health of individuals and communities and slow cost growth.

For example, Jane is a diabetic with erratic blood sugar that causes dizzy spells despite her medications. As a result she was often going to the ER. When she joined an ACO, however, she was able to eliminate these trips to the ER, because the ACO coordinated her care among her doctor, a nurse and a diabetes educator with whom she talks daily about diet and exercise. The educator schedules her appointments and works with her on her meal plan. When Jane has a bad day, she contacts the nurse who meticulously goes through her food intake and helps her make better choices.

Patient and provider participation in an ACO is purely voluntary. With baby boomers entering retirement age, health costs for elderly and disabled Americans are expected to soar. ACOs focus on prevention and make providers jointly accountable for the health of their patients, giving them strong incentives to cooperate, avoid unnecessary tests and procedures, and meet quality targets. ACOs do not do away with fee for service, but they create savings incentives by offering bonuses when providers keep costs down and meet specific benchmarks.

ACOs are not a panacea, however, they offer the promise of patient-centered care that incorporates case management, management of electronic medical records, care coordinators and use of data analytic systems to track populations.  This could mean a  healthier future for patients and potential cost savings to Medicare of up to $960 million in the first three years. Although that amount is far less than one percent of Medicare spending it is still a significant number that promises to grow.

Tuesday, March 27, 2012

Changes to Health Delivery System Key to Reducing Care Costs

With all the talk this week about Obamacare and whether or not the Supreme Court will declare the law constitutional, partially unconstitutional, or take no stand, the law will not have a measurable impact on the cost of health care delivery to patients until significant changes take place in the way the delivery system works.

There are several reasons why the cost of care has risen so radically, and there are measures that can be taken to reduce some of these costs, simply by changing patient and provider behaviors in areas such as medication adherence, fast access to care and preventive care.

Medical Adherence

One-third to one-half of patients in the U.S. do not take their medications as instructed. This leads directly to poorer health, more frequent hospitalizations, a higher risk of death and as much as $290 billion annually in increased medical costs. Non-compliance includes not taking medication on time, not sticking to the proper doses, or simply ignoring the medication by not filling the prescription, or filling it and not taking it. Reasons patients give for their non-compliance include: unpleasant side effects, confusion, forgetfulness, language barriers and feeling “too good” to need medicine. 

It is a known fact that patients with chronic conditions such as diabetes and high blood pressure are among the group less likely to follow their medication regimen. Perhaps if more providers were reimbursed based on outcome rather than on their fees for service, they would invest in the time, resources, counselling services, and necessary technology to educate patients and foster better adherence.

A study by researchers at NYU School of Medicine confirms that positive affirmation, when coupled with patient education, seems to help patients more effectively follow their prescribed medication regimen. How does that reduce costs? We know that with adherence comes better management of health issues. With better management of health issues comes fewer visits to the ER. With fewer visits to the ER comes lower cost of care because the patient who gets better by following the treatment prescribed does not need further intervention.

Access and Information

One of the most significant obstacles to improved patient care, at a reasonable cost, is access. The relative lack of real-time access to care and the absence of comprehensive patient information at the point of care are essential to improving outcome. Better access to care will lower the cost of care because patients do not have to wait to see their doctors and avoid having their health issues precipitate from an issue to a crisis. An example of that is an elderly woman who called her doctor’s office to request an immediate appointment for a rash that was painful and itchy and would not go away with topical medications. The doctor was on vacation and when the patient was finally seen several days later she was diagnosed with Shingles. Instead of a few days on an oral dose of an anti-viral medication, she ended up hospitalized for several days on IV medications, with a very severe case of shingles that had spread to several locations in her body.

The new patient-centered medical home model of care resolves some of these issues, by extending access to patients using the services of nurses, nurse practitioners, physician assistants and other well- trained professionals to deliver many basic health care services. With digital health records as a part of the medical home model, all of the patient’s information is available to all of these providers when the patient needs to be seen. This allows the physicians in the practice to focus on diagnosis and deal with the tough issues, while other competent, well trained healthcare professionals handle routine exams, coordinate follow up appointments, deliver counseling, and make sure that screen tests, vaccinations and other milestones for the patient are achieved.


Preventive Care

Prevention is clearly one of the touchstones of health care. To prevent deadly or disabling disease from occurring, or to stop it at an early stage, seems like an obvious way to cut health care costs and improve population health. Early intervention health and wellness programs are available but patients have to be willing receptors of these efforts, and providers have to spend time and energy to make these programs work. It is not an easy task. Some suggestions for carving out programs where preventive care is the focus include:

1. Doctors or their nurse practitioners or physician assistants have to provide patients with education and tools for proper weight control, fitness programs, stress reduction and relaxation techniques because we know that diet and fitness play a huge role in keeping people healthy

2. Immunizations and vaccinations need to be kept current. With the assistance of digital health records, there are no longer reasons why these should not be up to date.

3. Warnings about exposure to certain disease triggers need to be passed along to patients so they are aware of the risks when they travel or expose themselves to certain environments.

4. Doctors and patients have to engage in discussions about family history so they are aware of the genetic make up the of individual that could cause disease. Based on that information the patient needs to be sure to get certain screenings when appropriate.

Current initiatives in patient-centered care medical homes and accountable care organizations are a giant step toward collaborations between patients and physicians to jointly work toward better adherence, more immediate access and availability of information and better preventive care. These efforts will produce reductions in the cost of care but it will be a slow process.

Thursday, March 22, 2012

Virtual Book Signing with Behind the Story

Want to go to a book signing, but the long drive and lines turn you off? Now, the book signing comes to you! With the new Behind the Story virtual book signing event, you can experience a free book signing from the comfort of your home, office or wherever the day finds you. Each event lasts one hour and will feature four up-and-coming authors.

To attend our first online event at 2 p.m. EST on Tuesday, March 27, register here to receive your log-in information.

You will also have the opportunity to ask the authors questions during the event, and for attending the virtual signing, you will receive a free copy of my e-book.

Patient Engagement Will Improve Outcome

Engaging patients in managing and monitoring their health by using health information technology has proven to positively change outcomes. In a recent study of over 3,500 patients with diabetes and hypertension, conducted by Kaiser Permanente, (KP) the use of secure patient-physician messaging in any two-month period was associated with statistically significant improvements in their chronic conditions. Results included 2 to 6.5 percentage point improvements in glycemic, cholesterol and blood pressure screening and control.

The study, which was published in the July 2012 issue of Health Affairs, concluded that putting patients and their data at the center of care resulted in improvements in health care quality, access and cost. Using My Health Manager, Kaiser Permanente members sent over 850,000 secure messages to their clinicians each month.of the study. The clinicians logged in nearly 3.5 million messages between January and April, 2011 to their patients in email exchanges that were focused on helping those patients empower themselves and better manage their health.

There are reasons why the KP project, and similar programs foster patient empowerment and engagement. The availability of a secure portal where patients communicate with their clinicians to ask those questions that they forgot to ask during their face to face visit, or address issues that come up between visits, enables them to stay connected,on top of their health issues, and out of the emergency room. The reward of getting answers quickly and easily without the frustration of telephone tag or the consumption of large amounts of time out of their busy day, encourages patients to engage more. This in turn leads to better management of health issues.

To engage, patients need knowledge, skills and emotional encouragement so they feel confident enough to ask the right questions and become involved. Among the actions that patient who engage must undertake are:

Use technology to communicate with providers
Make treatment decisions
Seek health knowledge, particularly related to their own health issues
Understand health costs and make appropriate choices
Work at preventive health and wellness

These are giant steps toward changing behaviors and moving to patient-centered care. Patient engagement is a cornerstone of the patient-centered medical home. It takes total commitment from patients and providers to accomplish. Without an engaged patient you cannot have a viable team approach to care. Although there are challenges, engaged patients are essential to realizing the needed changes to our health care system that will result in better quality health delivery and cost efficiencies.

Tuesday, March 13, 2012

Patient -Centered Care and the Medical Home

In my last blog post, I talked about Patient-Centered Care, how the concept evolved, and where we are today. A medical home is a model of care delivery that enables patient-centered care. It is a health setting where a specific health care provider /physician leads a team of professionals who take care of you. Does this sound a lot like the old fashioned family doctor that your parents saw 50 years ago? -- a doctor who really knew you as a person and followed you from birth until you either died or left the practice only because you relocated?
The 21st century twist is that in today’s medical home you, the patient, are a member of the care team, and technology, including email, the Internet, digital health records, smart phones, and secure patient portals, helps facilitate your care and insure personalized care coordination and continuity. The medical home concept also includes a proviso that you have more access to your care team including open scheduling, expanded hours and new options for communicating with your team such as e-visits.

Three trends are building the current momentum around the medical home: (1.) a growing shortage of primary care physicians, thus the need for a team to pick up some of the responsibilities (2.) the increasing prevalence of chronic disease among the population that needs constant managing and monitoring, also enabled by the support of a team of providers, and (3.) the availability of health information technology (HIT) .

The escalation of health costs and growing numbers of individuals with chronic diseases, validates the medical home model that incorporates primary care physicians who lead multidisciplinary teams that include support staff such as nurse practitioners, physician assistants, pharmacists, nurses, social workers, therapists, and other care extenders. Underlying this assumption is the premise that HIT systems support coordination and continuity of patient care. Government initiatives, including incentives for physicians who adopt of electronic health records, as well as a cultural change in physicians’ attitudes toward implementation of health IT such as e-prescribing, web resources, smart phones and smart pads to communicate with patients and electronically monitor chronic conditions, will help the medical home concept gain traction.

Several pilot projects with the patient-centered medical home (PCMH) indicate the success of this approach. All of them employ care teams to coordinate and manage care with primary care physicians leading the teams.They also use health information technology to standardize work flow and to enhance the patient/physician relationship.

One successful pilot was held at Group health in Puget Sound, Seattle Washington. Group Health provides health care insurance and comprehensive care to approximately half a million residents in the northwestern United States, including twenty primary care clinics where patients choose a primary care physician to guide and coordinate their care. These physicians (81.6% family physicians, 3.5% general internists, and 14.9% pediatricians) care for an average of 2300 patients and work in multidisciplinary teams. Between 2002 and 2006, Group Health implemented a series of reforms to improve efficiency and access including same-day appointment scheduling, direct access to some specialists, primary care redesign to enhance care efficiency, and an electronic medical record with a patient Web portal to enable patient e-mail, online medication refills, and record review. The reforms succeeded in improving patient access. Group Health then developed a pilot of a patient -centered medical home (PCMH) redesign in a single metropolitan Seattle clinic serving 9200 adult patients with the goal of spreading lessons learned to other clinics. Structured around a thorough electronic medical record system, frequent patient communication, and regular medical team collaboration, this approach at Group Health improved patient satisfaction and reduced clinician burnout rates and reduced health care costs. With their PCMH, patients had 29 percent fewer emergency visits and 6 percent fewer hospitalizations, resulting in a net savings of $10 per patient per month. For every dollar Group Health invested, mostly to boost staffing, it recouped $1.50.This evaluation prompted Group Health to spread the medical home to all 26 of its medical centers, which it finished doing in January, 2010.

This is just one example of how an implementation of the PCMH results in successful patient engagement in care, coupled with improved working conditions for the physicians and significant cost savings. There is much promise that the PCMH could elevate the quality of health care for everyone and might just be the answer to many of our health care system woes.

Thursday, March 8, 2012

Patient-Centered Care, The Time Has Finally Come

One of the largest health care conferences, HIMSS (Health Information Management Systems Society) took place last week and patient-centered care and the patient role in the care team was a key topic. The realization that patients have more information about their diseases and treatment options and have the right as well as the understanding to be making decisions about their care in conjunction with their health care professionals has finally taken hold in the medical establishment. It is about time.

In 2001 The Institute of Medicine (IOM) published a study that outlined the guidelines for a new health care model, patient-centered care. The report attempted to explain why it is so important that the health care establishment change their approach of treating disease and prescribing medication that most providers learned in their medical training, to an approach that centers on the whole patient and not on the particular disease that needs to be treated. The IOM described patient-centered care as:

“Respectful of and Responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical encounters.”

The IOM suggested ten rules that the 21st century health care system should follow. They include:

Rule #1 Care based on continuous healing relationships.
Rule #2 Customization based on patient needs and values
Rule #3 The patient as the source of control
Rule#4 Shared knowledge and the free flow of information
Rule #5 Evidence-based decision making
Rule #6 Safety as a system property
Rule #7 Need for transparency
Rule #8 Anticipation of needs
Rule #9 Waste continuously decreased
Rule #10 Cooperation among clinicians

(Crossing the Quality Chasm , National Academy Press, 2001, pages 6,1 66 - 83)

It has taken the entire decade for most health professionals to recognize the importance of this approach and incorporate the rules outlined by the IOM into standard practice. It has taken a decade for the health care system to finally admit that including the patient in the care team. and providing patients with the information to participate in the decision process will result in better, safer, more efficient care delivery and better outcomes, while controlling costs. Hopefully this will resolve some of the problems inherent in our current system.

Sunday, February 19, 2012

Are Patients Consumers?

When you are relaxing and watching your favorite evening television program or surfing the Internet and advertisements pop up for a cholesterol, anti-aging or arthritis medication, it leaves no doubt in your mind that you are being targeted as a consumer of health care.

Wikipedia defines a consumer as an individual who uses goods generated within the economy. As a health care consumer you need to be equipped with the information to choose your providers, medications and special services, based on the right price, features, brand recognition and appeal.

In the past if you had a medical problem, you saw your local general practitioner. He or she suggested a treatment and you generally followed those recommendations with little decision-making desire or power on your part. You were okay with that.

Today, there are so many variables, including cost vs coverage, efficacy of the treatment, and complex evidence-based diagnoses, that force the patient to shop for health care and make choices. The development of consumer directed health plans that most employers support because they save money, put you in the driver’s seat when choosing health insurance. These plans give you options for choosing your provider, hospital, pharmacy and other peripheral services such as therapists and clinics. They encourage you to choose health savings programs and flexible spending plans which include high deductibles and ways to put aside money to help pay for extraordinary health expenses should they arise. The cost analysis involved with consumer directed health plans forces you to stop and think about whether or not to seek treatment or put it off; whether to go to the community hospital or look for a specialist at a large academic teaching hospital where the costs are higher; whether to take the newest medication developed for a particular condition or a generic that will be cheaper and covered by the plan. Does this force you to become an educated consumer of health care? You bet.

This is not a bad thing. It is the way you are empowered with the information and financial responsibility to own your health care decisions and deal with your health in a holistic way rather than engaging in a knee jerk reaction to sickness and disease. It is a way of forcing you to plan and take actions that reinforce wellness prevention, compliance, treatment and early intervention programs. There is no question that consumerism in health care is a fact that you cannot avoid. Whether or not it will help to improve the quality and efficiency of your care and result in better outcomes is up to you.

Monday, February 13, 2012

How to Find Good Health Information on the Web

It is a well established fact that empowered patients go to the web when they need to find information about health issues. Pew research indicates that 80% of Internet users search online for their health information and that translates into 59% of the total population of the United States looking online for health information for themselves or someone that they care for. These individuals are seeking information on symptoms, treatments, medications and general health such as food and safety issues. Many of these individual belong to Facebook and Twitter. This raises the questions:

Where do these individuals look for health information?  
Should they rely on heir social networks? 
What are some of the reliable, focused health sites?

There has been major discussions about Facebook recently, which now has over 800 million registered users and has an IPO pending. Facebook claims that there are approximately 175 million individuals who log in daily but these estimates vary widely. For the most part, Facebook visitors are connecting with friends on a variety of personal/social issues and are not specifically seeking health information. On the other hand there have been some remarkable stories of Facebook users finding organ donors and other health assistance and information through this social network. So if you are on Facebook and have a health need or a question, it never hurts to put it out there to your friends.

What about Twitter? Twitter claims to have 175 million accounts. Looking closely we find that of those, 56 million Twitter accounts follow zero persons and 90 million have zero followers. No information exchange there The rest include small numbers of individuals who follow significant numbers of accounts and a very small percentage who seek health information. Among the health seekers there are tweets and links to a very wide range of resources and issues. Therefore if you like to tweet and are an information junky twitter may be helpful.

There are social networks specifically devoted to patients who are looking for information and communities with whom to share their concerns and thoughts. They are worth checking out and include:

Web MD

The most popular of the general health information consumer web  sites is Web MD. Web MD has over 80 million unique visitors each month. The site offer just about everything a health care consumer needs, including a symptom checker, a comprehensive database of drugs and medications, a directory, women’s health information, and general health issues related to diet, fitness, recipes, life style, exercise and safety. The site includes pod casts, videos, tool kits, training materials, an e-newsletter, even a section on the health of your pets. There is a Web MD app that can be downloaded for all popular smart phones. Web MD does accept advertising so some of the content on the site could be influenced.

Mayo Clinic

The Mayo Clinic web site offers user friendly content and includes mainstream questions and concerns for consumers, health care professionals and educators. All of the information is vetted by health care professionals. Information on diseases and conditions, a symptom checker,. drugs and supplements, tests and procedures, healthy living as well as information on how to provide first aid on conditions from tooth aches to animal bites is available. There is no advertising on the Mayo Clinic site. is a popular, up-to-date source of free drug information online.  it is based on peer-reviewed accurate and independent data on more than 24,000 prescription drugs, over-the-counter medicines and natural products. 

Health Grades

At this site, patients can find doctors, dentists, and hospitals by specialty and location. The individuals and institutions are profiled and rated by patients.  The information is objective and reliable.

Department of Health and Human Services,

This gateway site links to a broad range of consumer health information resources and enables the consumer to search for medical, pharmaceutical and health information from over 1,500 websites, online publications, clearinghouses and databases on every conceivable health topic.  It is one of the hidden gems for health information on the web and for the health information seeker is well worth checking out.

There are many other excellent web sites that address specific diseases and issues. A more comprehensive list can be found in my book, e-Patients Live Longer, The Complete Guide to Managing Health Care Using Technology

Thursday, February 2, 2012

Is That Screening Test Really Necessary?

“We are in the midst of an epidemic of diagnosis. Conventional wisdom tells us that this is good. Finding problems early saves lives, because we have the opportunity to fix small problems before they become big ones. What’s more, we believe that there are no downsides to looking for things to be wrong. But the truth is that early diagnosis is a double-edged sword. While it has the potential to help some, it always has a hidden danger - overdiagnosis - the detection of abnormalities that are not destined to ever bother us.”

Overdiagnosed: Making People Sick in the Pursuit of Health by H. Gilbert Welch, Lisa Schwaretzl, Steve Woloshin, published by Random House, 2011

We are getting mixed messages about whether or not screening for cancer and other diseases is a good thing or a bad thing. We read in the media that early, aggressive treatment is always best, yet some have begun to question that mantra. The belief that cancer screening, for example, will save your life has come under attack. Research now confirms that some cancerous tumors would, in fact, never cause harm because they are too slow-growing to ever threaten your life. Others are so aggressive that finding them early does not make much difference. Then there are the situations where early detection can make all the difference, actually stopping diseases before they start, e.g. testing blood sugar for diabetes, checking blood pressure, cholesterol and EKG for hypertension and other cardiac issues.

Dr Welch issues a reasonable call for change that would save patients pain, worry and money when he contends that “overdiagnosis is a big problem with modern medicine that leads millions of people to become patients unnecessarily while adding huge costs to an already overburdened system.”

So what is an intelligent empowered patient supposed to do when, for example, there are qualified medical providers who clamor for eliminating screening for prostate cancer and postponing mammograms, while other qualified providers are not only encouraging these screenings but insisting on them for their patients?

We know that many of the screening tests have risks, including false positives that lead to invasive biopsies and in some cases irreversible side effects. On the other hand if we look at mammography we also understand that although mammograms don’t prevent breast cancer they can save lives by finding tumors as early as possible. Overall mammograms pick up 80-90% of cancers and have shown to lower the risk of dying from breast cancer by 35% in women over the age of 50. In women between ages 40 and 50 the risk reduction appears to be somewhat less. Some groups including the National Cancer Institutes, the American Cancer Society and the American College of Radiology currently recommend annual mammograms for all women over the age of 40. Others suggest that screening for breast cancer does not need to begin for the general female populace until age 50, with obvious exceptions such as women with a family history of breast cancer.

Creating even more confusion are the results of two long-awaited studies - one conducted in the United states and the other in Europe. These studies were supposed to settle the debate over the value of PSA (prostate cancer) testing. These trials, published in the New England Journal of Medicine, March 2009, appear to reach opposite conclusions. The Prostate Lung Colorectal and Ovarian (PLCO) Cancer Screening Trial reported no survival benefit with PSA screening and digital rectal examination. The European Randomized Study of Screening for Prostate Cancer (ERSPC), however, found a 20% reduction in prostate cancer deaths. The ERSPC study estimated that for every life saved, 48 men are treated and 1,068 men are screened.

Is it therefore left to the patient to figure out whether to undergo screening or not? This is one of the best examples of why being an empowered patient is so important. The patient must weight the benefits and risks, talk to your physicians and ask the following questions:

1. Which test do you recommend for me and why?
2. How much do the tests cost
3. Will my health insurance help pay for these screening tests?
4. How soon after the tests will I learn the results?
5. If the results show a problem, how will we learn if I have cancer?
6. What are my choices once a diagnosis is confirmed?

Patients also need to be sure that their physicians follow a sensible protocol before rusiing into screening tests, including the following:

1.Physical exam and history. This exam checks the body for general health as well as signs of disease such as lumps or anything else that seems unusual.

2. Laboratory tests. A first step following the physican exam should be the least invasive screenings including blood and urine

3. Imaging procedures including mammography might be the next step because they are also less invasive

4. Genetic tests executed by drawing blood, that look for certain gene mutations (changes) that are linked to some types of cancer are another non-invasive screening option, although they are quite costly

5. Finally if there is enough evidence, a biopsy might be warranted.

It is up to each patient to drive the screening process, communicate with your physician at every step and weigh all the alternatives before agreeing to tests that may not, in the long run, change your outcome. Below are websites that have cancer support advice and tool kits.

Tuesday, January 17, 2012

The Opportunities and Threats with Open Notes

We know that more and more physicians are implementing electronic health records. (see post Thursday January 12, Update on EHRs). Now the question becomes how do patients share the information in those records so that they are better informed and can be empowered to do more about their health issues? Dr. Tom Delbanco at the Beth Israel Deaconess Medical Center in Boston (BIDMC) has come up with a solution entitled Open Notes, which would give patients access to the doctor’s notes in their record through a secure online portal.

A pilot study of Open Notes that included 25,000 primary care physicians and patients from the BIDMC, Geisinger Health System in PA, and Harborview Medical Center in Seattle WA, and funded by the Robert Wood Johnson Foundation, concluded that patients really like the idea because they see this as a way to a greater understanding of their issues and more involvement with their care. Physicians on the other hand are less than enthusiastic and have concerns about accountability and privacy of patient information.

Patients do have the legal right to their health record. They can request copies and changes to them if they’re inaccurate. With the digitization of health records the data included is readable , although not always understandable for the average individual. Historically, test results, lab reports, medication lists and medical history comprise the record turned over to the patient upon request. The copy does not include the doctor notes. Patient respondents who were very enthusiastic about Open Notes felt that reading notes taken during their visit with their primary care physician would help them grasp more thoroughly what the physician recommends and help in following the treatment plan. In addition, many patients indicated that they would share the notes with other physicians/specialists who were treating them concurrently. A third of the patients had concerns about the privacy of their health information.

The issue here is how communication between doctor and patient is handled and the trust relationship that is in place with full disclosure of notes. Physicians must be protected from the litigious nature of many patients who might decide to challenge what is in the notes. This could be a problem since there is currently no legislation that specifically addresses this issue. Patients must be protected from the delivery of their notes to unauthorized individuals or inadvertently to social networks and other public exposure. There is also the issue of secure communication of this information. There are only a handful of physician practices or hospital physician groups that have the type of secure portals necessary for enabling the communication of notes in an environment where the privacy of this information is well protected.

As digital communication technology becomes more ubiquitous, empowered patients and enlightened physicians have many practical and ethical considerations, including Open Notes policies, as we all strive toward the goal of better quality, safer medical practice.

Thursday, January 12, 2012

Update on EHRs

Nearly 57% of U.S. office-based physicians by the end of 2011 were using some type of electronic health record (EHR) up from 51% in 2010 and 48% in 2009. About a third of physicians (34%) report that they meet the criteria for a basic electronic health record system and 52% of physicians report that they will apply for meaningful use incentives this year, up from 41% in 2010. This means that giant health care physician networks as well as small independent primary care practices are finally agreeing on full adoption of electronic health records.

First introduced in the 1960s, the implementation of EHRs has been a long struggle because these systems are time consuming and costly for the overly cautious, over-extended physician who has resisted changing the way patient records are kept. One of the drivers persuading physicians to commit to EHR implementation is the 2009 federal economic stimulus package that stipulates that health care providers who demonstrate meaningful use of certified EHR systems qualify for Medicare and Medicaid incentive payments. The federal government is investing $20 to $30 billion in stimulus money to promote EHRs through a system of 62 regional extension centers. The centers are hosted by a variety of entities from government agencies to non-profit health care consortia. The extensions have been given the formidable task of selling and supporting the switch to EHRs across the country.

An EHR is an electronic version of a patient’s medical history that is maintained by the provider over time and may include all of the key administrative clinical data relevant to that person;s care, including: demographics, progress notes, problems, medications, vital signs, medical history, immunizations, laboratory data and radiology reports. The EHR automates access to this information and has the potential to streamline the clinician’s work flow and make it possible for patients to share this information and thus share in decision making. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces including evidence-based decision support, quality management and outcomes reporting. The good news is that with an EHR there is no more missing information at the point of care ; no more searching through a paper file to look for the results of a previous test, while the patient is sitting and waiting; no more lost charts. Done correctly, EHRs streamline interactions between all players on the health care front from pharmacies and labs to ambulance crews and insurance companies.

EHRs are also the next step in the continued progress of the health care system to strengthen the relationship between patients and clinicians and enable clinicians to make better decisions and provide better care. For example the EHR can improve patient care by:
  • Reducing the incidence of medical error with the improved accuracy and clarity of data.

  • Making health information available to patients

  • Reducing duplication of tests and delays in treatment.

Blue Cross & Blue Shield of Rhode Island recently announced results of a multi-year pilot program designed to increase the use of electronic records , transform the way health care is delivered, improve members’ health and help moderate health care costs. Results of the pilot which became the foundation of BCBSRI’s patient-centered medical home model demonstrate the value in using health information technology to improve quality of care. Highlights of the pilot include the following:

  • Lower monthly health care costs that averaged between 17 and 33 percent less per member than those receiving care at non-participating practices

  • Improved health care quality with a 44 percent median rate of improvement in family and children’s health, 35 percent in women’s care and 24 percent in internal medicine

  • Successful EHR implementations for 79 local physicians

A recent article in the New England Journal of Medicine (December 15, 2011) showed that EHRs improved the quality of care for patients with diabetes by reducing unnecessary testing, helping to prevent adverse events and improving patient care coordination as compared to practices that use paper-based methods.

All of these studies and examples would lead us to believe that the EHR has finally established its worth to the medical community and once we approach 100% participation, patients can be assured that they and their providers will have access to their health information at the point of care. The availability of digital health information will enable patients to use email, portals,. and e-visits to more effectively and efficiently communicate with providers and to use smart phone apps to monitor their health. As a result they will experience better, safer medical care.