Health for life

EHR portals at work?

The Disease Management Care Blog had this thoughtful reply logged onto its "Follow-Up" post on the topic of EHR patient portals. Logged by Rebecca M Coelius MD, Medical Officer for Innovation at HHS/ONC, the DMCB recognized that this was important enough to warrant its own separate page.

While we wish that the results were more conclusive and positive, the Office of the National Coordinator for Health Information Technology (ONC) applauds the meta-analysis and the recent upswing in articles on patient portals and other patient-facing technologies. The number of patients and caregivers who desire greater participation and transparency in their healthcare makes continued research in this area vital. Yet, in a close read of the full Annals of Internal Medicine meta-analysis article and in many of the studies it cites, there were unquestionably statistically significant positive clinical outcomes, as well as positive patient experiences, associated with certain patient portal functions.

The ONC does not believe that Health IT alone is a panacea, or that meeting the form of Meaningful Use, while not embracing the new functions the technologies it enables, is likely to result in measurable improvements. The study authors caution that it was case management that tipped the utility of portals from unclear or small to more substantial, but it is important to note that the case management activities happened via the portal itself. This is a perfect example of Health IT as an enabler of new ways of reaching and caring for patients; we would not separate the two concepts.

To the study’s described limitations, we offer two significant additions. First, the definition of a patient portal remains loosely specified, so it is difficult to make conclusive statements about the entire category. The meta-analysis did attempt to list which functions were present for each study, but half of the studies that looked at patient outcomes gave only a partial description of portal features, and a deeper assessment of the quality of functions and their relevance to the outcomes measured was not present for any study.

A more illustrative future approach would be to evaluate individual functions of portals for impact on patient participation in their care and specific health outcomes, and then ask what design principles and organizational contexts were necessary to make that function successful. For example, the impressive OpenNotes project demonstrated that patients with access to provider notes had a better understanding of their health and condition, improved recall of their care plan, and increased likelihood of taking medications as prescribed. In a New England Journal of Medicine study on weight loss interventions, over twice the number of patients in the remote support intervention groups (telephone, website access, and e-mail support) lost more than 5% of their weight versus the control group. Secure messaging and the ability to view personal health information are two cornerstones of portal functionality within Meaningful Use.

Second, more than 10% of these studies are ten years old, and over a third were published five or more years ago. We understand the necessity of adequate numbers for meta-analyses, but statistical significance does not necessarily confer relevant insights. Technology, and patient perences and capabilities for using technology have fundamentally changed over the study time periods included, not to mention the maturation among health-care organizations themselves and the expectations of patients.

The very premise of the patient portal is a rapidly ageing one. As the ONC articulated in a 2013 Health Affairs article, there are shifting attitudes related to the traditional roles of patients and providers, and exploding demand and penetration of smartphones, health and wellness apps, and connected devices. We are moving the conversation from engaging people with our existing healthcare system through “portals”, to using technology to move outside our system to reach them every day where health truly happens. What we need to measure and incentivize in the future is not the value of portals, but the value of delivering the right information and intervention to the right person, at the right time, through the right interface based on an individual user’s context.

Two points deserve emphasis:

1) Physician liability insurers (the companies that defend physicians against allegations of malpractice) are paying close attention and could use information like this in their underwriting.  It seems some are ready to conclude that bad EHRs can not only lead to patient injury, but may deserve increased premiums.

2) Nothing spurs action more than the threat of an outside or unfriendly regulator or government entity willing to independently collect this kind of information and act on it.  The DMCB wonders if that was one ingredient in the formation of this initiative.

The DMCB is looking forward to seeing the numbers in the coming months.  Stay tuned!

(From time to time, the Disease Management Care Blog welcomes commentary from its readers.  Heres an interesting thought.....)

As a long-term reader, I thought the erudite but contrarian and sometimes snarky DMCB might be the best venue to ask others of my ilk to comment on an observation of mine.

I am a primary care provider working at the quantum level of patient care.  I am in my second year of full fledged EHR use.  It is obvious to me from the consultation notes that I receive on an hourly basis that most of my colleagues are also on board.  Journal articles as well as my first-hand experience have convinced me that we have indeed reached the tipping point of electronic record use. 

Since this milestone passed, I have noticed a change in the focus of office notes and consults.  I am seeing neurosurgeons document conversations regarding the safety of patients relationships and whether or not they feel threatened.  Podiatrists routinely document the existence of living wills.  Dermatologists are now savvy about the sexual activity of octogenarians with actinic keratosis. Despite my consultants thoroughness in their care (and conversations with health care students who have rotated through these specialties make me believe that some specialists are using telepathy to document things), I am not seeing traditional assessment and plans at the end of the encounter. 

What I usually see is the same generalized diagnosis code that I sent them with followed by a list of tests cluttered with a erences to various quality metrics that are inspired by systems such as HEDIS®.  The old fashioned differential diagnoses or thoughtful prose concerning the evaluation is conspicuously absent. 

I call this my hypoplastic hypothesis.

As a primary care physician, when I consult a colleague, I am really asking the specialist “Hey, what do you think?” Prior to the advent of the EHR, much of my continuing medical education has come from the insights that I use to get from these consults. Now Im reading about feeling threatened, living wills and sexual activity.
 
How did we get here?

When I was an undergrad in Biochemistry, during the dreaded Physical Chemistry course, we learned about the observer effect and the Heisenberg uncertainty principle. Wikipedia defines both as:

"In science, the term observer effect ers to changes that the act of observation will make on a phenomenon being observed. This is often the result of instruments that, by necessity, alter the state of what they measure in some manner. A commonplace example is checking the pressure in an automobile tire; this is difficult to do without letting out some of the air, thus changing the pressure. This effect can be observed in many domains of physics.....However in quantum mechanics, which deals with very small objects, it is not possible to observe a system without changing the system, so the observer must be considered part of the system being observed.

In quantum mechanics, the uncertainty principle is any of a variety of mathematical inequalities asserting a fundamental limit to the precision with which certain pairs of physical properties of a particle known as complementary variables, such as position and momentum, can be known simultaneously. For instance, the more precisely the position of some particle is determined, the less precisely its momentum can be known, and vice versa."

In my opinion we now have a new phenomena that parallel the laws of physical chemistry:  I call it the HEDIS uncertainty principle. 

The actual act of measuring HEDIS® scores and other similarly contrived quality metrics has fundamentally intruded into the quantum level of physician care.  Does this measurement change the behavior of the particles of the system and alter the ultimate structure of the encounter?  Are the data still reliable and the measurements still accurate?  Have the impressions and treatment recommendations indeed become hypoplastic, or has the encounter remained unchanged but the documentation is skewed to HEDIS®? Is the question asked of the consultant answered but not documented?  If not, what does this portend for disease management and health care quality?

I have my suspicions, but I would like to tap the wisdom of the DMCB readers for theirs.

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"Hi doc! I used my on-line portal to make an appointment!"

Hey there Accountable Care Organization executive.

Youre probably willing to continue to commit millions of dollars toward an electronic health record (EHR) coupled to an online patient portal.  Thats because youve been told by your leadership team that electronic consumer empowerment, patient-provider communication and the substitution of efficient two-way messaging for costly face-to-face visits will increase quality, reduce expenses, generate shared savings and guarantee that your life-sized portrait will be prominently displayed in your flagship hospitals lobby.

Well, after youve read a just-published JAMA research study by Ted Palen, Colleen Ross, David Powers and Stanley Xu, you may want to tell your administrative assistant to cancel that appointment with the portrait artist.

The articles title is Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services.

How the study was done:

Kaiser Permanente Colorado added "MyHealthManager" (MHM) to their EHR in May 2006. MHM allows patients to view tests, records, problem lists as well as care plans, schedule appointments, request ills and message their doctors. By June of 2009, over 375,000 Kaiser patients had signed up for MHM. Of those, about 45% had used the system at least once.  Of this number, Kaiser researchers pulled the records of 44,321 persons who had been continuously enrolled in the Kaiser system for at least two years. 

This group was retrospectively matched to a control group of Kaiser patients who had not signed up for MHM.  The authors did this through "propensity matching." This found a similar number of patients, based on age, gender, race, number of chronic illnesses and baseline office visits who, using logistic regression analytics, appeared to be the type of patient who would otherwise sign up for MHM.

The results:

Compared to non-MHM patients, the MHM experienced an increase in hospitalization rates (20 per thousand patients) and emergency room visits (11 per thousand).  In other words, for every hundred patients, the on-line portal seemed to lead to 2 extra hospitalizations and 1 extra ER visit. Both differences were statistically significant.

There were also increases in the number of office visits (.7 per patient per year), telephone calls (.3 per patient per year) and after-hour clinic visits (18.7 per thousand patients per year).

Caveats:

The authors correctly point out that this study is not perfect.  Retrospective propensity matching is not as good as a randomized clinical trial; its possible that the patients who self-selected for MHM were already realtively more interested in or likely to increase their use of health care services.  Results at Kaiser may not apply elsewhere.

Implications:

Despite the limitations, this study should be a wake-up call for those who believe EHR portals is a savings panacea.  By increasing access to on-line services, physicians and patients may paradoxically use the system to address concerns that otherwise wouldnt come to medical attention.  In other words, the EHR portal exacerbates the classic health care economics problem of supplier-induced demand.

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"Crawling" an EHR for text?

Readers may recall a prior Disease Management Care Blog post that describes the potential of "natural language processing" (NLP) in population health and disease management.  Since much of the electronic health record (EHR) still relies on free text, its difficult to extract and pool useful data from the system. 

For example, if the DMCB types that the patient "has a 10 year history of diabetes" in a clinical encounter note without otherwise officially documenting that condition in a "diagnosis field" or "billing code," the presence of diabetes wont be electronically recognizable.  The good news is that NLP is getting to the point where, much like a classic "web crawler," it can be used to "scan" free text and look for phrasing that identifies otherwise silent and undocumented diagnoses or treatments.

The good news is that theres this article courtesy of Fierce Healthcare that, in addition to saying nice things about the DMCB, gives a lot more background on the art and science of NLP or "computer assisted coding."  It turns out that its been under development for more than ten years, can generate physician reminders and by inferring a diagnosis, automate the tedious exercise of coding a patient visit.

The DMCB likes the notion and would make two other points:

1.  It doubts current EHR vendors will develop an NLP capability because they cant commercialize it and its not in the meaningful use criteria.  As a result, this functionality will need to be "bolted on" by a third party.  The companies that can develop a single solution that not only fits multiple EHRs but can adapt to a health information exchange will win.

2.  Speaking of meaningful use criteria, its time to include NLM.  Its ability to find patients at risk, facilitate population-based program planning, assist in predictive modeling, infer and automate diagnosis coding, generate reminders and act as an early warning system for outbreaks of disease make its  potential too great to ignore.

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Hal of 2001: A Space Odyssey

The Economists recent scrutiny of battlefield and automotive robotics prompted the Disease Management Care Blog to ponder the parallels of "robot-like" health care. 

Sounds too weird, you say?  Alarmist?  Silly?  Read on.

Consider the following scenario:

After checking in with her primary care provider, a check of Mrs. Smiths (not her real name) diabetes revealed her blood sugar was not in the generally recommended A1c range of 6.5-7% (see page 16).  She was free of low blood sugar spells and was otherwise healthy. The electronic health record (EHR) decision support protocols (like "Diabetes Wizard") prompted the care manager to OK a standard increase in Mrs. Smiths insulin dose ("Share the Care"). This was not only consistent with good clinical practice, the decision promised a pay-for-performance payday for the docs employer and fewer costly complications for the health insurer.
 
Several days later, her fatal car accident was ascribed to low blood sugar.  It turns out that the science of blood sugar control is still evolving, because tight diabetes control isnt necessary associated with better outcomes. In response, the Smith family lawyered-up.

The Economist article asks about the legal dilemmas inherent in robotic decision logic.  Can battlefield drones be adequately programmed to protect civilians?  Can driverless cars intentionally run over a dog if it means avoiding a child? Short of banning these automatons entirely, its obvious, says The Economist, that were going to have to develop a legal framework to deal with them: 

"...laws are needed to determine whether the designer, the programmer, the manufacturer or the operator is at fault if an autonomous drone strike goes wrong or a driverless car has an accident."

The DMCB agrees and suggests that this sensible recommendation be extended to the health care arena. EHR clinical programming may only imperfectly reconcile maximum near-term safety with longer term outcomes and fail to discern the subtleties that favor one treatment over another.

While white-coated plastic and metal cybertrons arent taking care of diabetic Mrs. Smiths (yet), machine logic reminiscent of "Hal 9000" of 2001: A Space Odyssey already is. Instead of an unblinking red orb, there are on-screen decision-support icons. Instead of a disembodied voice, there are clinical pathways (for example, see page 8). And instead of having control over vacuum locks that exit to space, these computer entities are using logic trees to direct, prompt and recommend that doctors and their team-nurses to chose treatment "A" over treatment "B."  If you think that the DMCB is being alarmist, consider that decision support, at last count, is involved in 17% of all outpatient visits in the U.S.  Thats a lot of legal exposure.

Thats why reasonable laws are needed here too, since its unclear how physicians, care managers, decision support programmers, EHR manufacturers (even with their notorious hold harmless clauses), physician clinics and health insurers would share in the culpability for allegedly awry decision-making.  Since, in the current U.S. tort system, all could be named in a suit, the risk is arguably intolerable. Just ask any physician, whose dread of being sued has already resulted in billions of unnecessary costs. 

Allowing that dysfunction to creep into computer-based clinical decision will increase costs there too, add uncertainty and slow adoption. 

The Economist has it right.

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Let thousands bloom

After reading this Huffington Post (HuffPo) article by National Physicians Alliance board member Ricky Choi, the Disease Management Care Blog is worried.

According to Dr. Choi, sometime last week, the White House hosted a meeting of national physician leaders to talk about the Affordable Care Act.  HHS Secretary Sebelius was there along with other CMS administrators.  The conversation focused on electronic health records (EHRs), the patient centered medical home (PCMH) and accountable care organizations (ACOs). 

The DMCB is not worried about another Cabinet member blurring the line between policy and election-year political grandstanding.  It is not concerned that naive ACA supporters are unwittingly being used to promote the Administrations health orm nostrums.  It is not surprised that this flattering article seemed only fit for liberal HuffPo and is destined to reinforce the biases of an already committed base. It is not wondering about a curious commitment to care approaches that still are not conclusively backed up by a critical mass of peer-reviewed evidence. Finally, the DMCB isnt shocked that it was not invited to the White House.

Rather, says the DMCB, its worried that this is all the White House has.  A precious day of CMS leadership attention spent in recycling stale EHR, PCMH and ACO acronyms and jargon with a fawning circle of fellow ideologues? What gives?

While the CMS EHRs meaningful use program continues, health care technology is evolving away from fixed desktops and mainframes toward mobile smart devices, apps, the cloud and social media. The transition is bound to shift doctors and patients highly personalized management of information in ways that we havent thought of. 

CMS "PCMH Ver. 1" entails a wholly contained primary care provider team reimbursed with a monthly fee.  In the meantime, other health systems and insurers are already figuring out how to simultaneously out and insource team members depending on local resources and patient risk. 

CMS is just getting its ACO pilots and programs off the ground. In contrast, commercial insurers launched a host of "accountability" initiatives years ago. Many are focused on a single clinical domain (such as avoidable emergency use, patients who are high risk, or post-discharge readmissions) and are highly flexible and expandable.

The distinctly modular approach to health IT, medical homes and provider-insurer risk transfer certainly contrasts with CMS plodding one-size-fits-all and top-down planning.  While a thousand commercial sector flowers bloom, CMS risks presiding over demos and pilots that could become obsolete before the the data collection has been completed.  Why arent they meeting about that?

Last but not least, the Administration seems to be putting all of the ACAs eggs in the EHR, PCMH and ACO baskets. If they dont work out, it would further undermine the brand of the star-crossed Affordable Care Act.

Image from Wikipedia