Health for life

The Disease Management Care Blog remembers when it was first introduced to an electronic health record (EHR).  After many days of learning how to document, link, retrieve, order, manage, view, bill, sign-off and close patient encounters, it asked about retrieving summary statistics on its patient population.  It wanted to know how many if its patients with high blood pressure were under control and how many of its patients with heart disease had low cholesterol levels. 
The practice administrator looked at the DMCB like it was crazy.

That was when the DMCB realized that the purpose of its EHR had less to do with quality, costs, coordination and everything to do with perpetuating the "hamster wheel" of one-on-one primary care.  Prior to the EHR, it averaged about 4-5 patient visits per hour.  After the EHR, that didnt change.  Neither did its HEDIS® measures, patient satisfaction rates or professional well-being.  The only thing that increased was its cumulative billing amounts.  No wonder the DMCB has been an unrepentant EHR skeptic.  It concluded that the purpose of the EHR is to perpetuate the dysfunctions of one-on-one care.

Articles like this, however, may change the DMCBs mind.  Jennifer Frankovich, Christopher Longhurst and Scott Sutherland describe how they tapped their local EHRs multi-year database to assess the outcomes of a cohort of patients that was similar to one of their own.  After analyzing how prior patients under similar circumstances fared, they decided that it would be a good idea to treat their patient with a blood thinner.  The patient ended up doing OK.

1.  Normally, a physicians expertise is built over the course of many patient encounters.  Thats called "clinical wisdom."  Being able to compact years of an institutions collective experience from an EHR into a spread sheet is not only a step in the right direction, its using the EHR to build an institutional body of wisdom.

2. This is another case study on the important distinctions between observational data bases (imperfect but locally relevant and readily available) and pristine evidence-based prospective randomized clinical trials (the gold standard for collecting evidence that is often lacking).  The latter is the standard of care and the enemy of the good; the former is quite useful and, as this case shows, often good enough.

3.  Last but not least, this is a good example of "applied" "population health management" in which a virtuous cycle of measurement can drive the local standard of care.  Its not only true for patients with obscure and rare diagnoses but for those with common, chronic and expensive conditions.  Want to reduce the burden of obesity?  Understand what really works for diabetes?  Tackle the costs associated with hypertension?  Assembling and using an electronic data base like this will make it possible.

The DMCB is looking forward to when future EHRs can perform at this level everywhere all the time.

Talk about a compelling story that went ignored.
In the November 19 issue of the Annals of Internal Medicine, Caroline Lubick Goldzweig and colleagues examined the published science on the purported advantages of electronic health record (EHR) portals.

Recall that portals are web-based entryways that on-line health consumers can reportedly use to access their records, request medications, correspond with their doctors, manage their health conditions, reduce health care costs, increase U.S. life expectancy, reduce our national dependency on jumbo-sized sugary drinks and fix everything else that ails the U.S. health system.

Unfortunately, facts have intruded.  After looking at fourteen randomized prospective trials, 21 observational, hypothesis-testing studies, five descriptive studies and six qualitative studies, the authors concluded...

 "...evidence that patient portals improve health outcomes, cost, or utilization is insufficient."

Ouch. 

In particular, any impact on diabetes care was short-lived or nonexistent, patients with heart failure had no meaningful improvement, blood pressure control did not improve and adherence to prevention recommendations were marginal.  One observational study found persons with heart failure were more likely to use the emergency room.  The only study that found any benefit involved a single randomized control trial that examined the impact of portals in the co-management of depression.

After looking at this review, depressed advocates of EHR portals may have to personally use their own portals to communicate with their docs health care medical neighborhood.

The only good news is that there were some data that suggested that a substantial number of consumers liked using the portals.  But the DMCB likes channel surfing too, but that doesnt mean that the spouse agrees that its television-watching quality has improved or that the cost of all those premium channels is moderating.

The authors pointed out that it was difficult to isolate the impact of a portal vs. a portal plus care management.  To the DMCB, that means that portals are at best a means-to-an-end of enabling care managers to better communicate with their enrollees. 

To the thousands of DMCB readers, that is not a surprise.

In the meantime, the Feds and the NCQA have one more reason to re-examine their many cherished assumptions about health information technology and the stand-alone electronic record. The last time the DMCB looked, the federal government continues to extoll portals stand-alone virtues. The National Committee on Quality Assurance (NCQA) still includes two way communication for appointments, errals and prescription errals as a standard for the medical home.  Finally, the Feds promotion of the electronic health record (EHR) approves of portals as an option in meeting meaningful use criteria.

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It was just a matter of time until this would happen.

Buried in the middle of this New York Times article on The Ups and Downs of Electronic Medical Records is the observation that a Medicare administrative contractor dubbed National Government Services has announced that it, on behalf of CMS, will "deny payment" for medical services that are documented in an electronic health record (EHR) using "cloned documentation."

The topic was covered more than 2 years ago by the DMCB here.  "Cloned documentation" is the widespread practice of copying, pasting past documentation in an EHR into the current encounter record to inflate the recorded patient evaluation to primarily justify a higher payment.  Thanks to this OIG report, the Feds have figured out that the true value proposition for an EHR is not "meaningful use" but wasteful abuse.

In addition to congratulating the Times for their crack cutting-edge reporting, the Disease Management Care Blog has a prediction....

1. The mere threat of payment denials and the possibility of sanctions will prompt health administrators everywhere to announce at medical staff meetings that "cloned" notes are verboten.

2. Until the "templated note" functionality is deleted in future EHR software updates, physicians will respond to this latest edict from their administrators in the traditional manner: theyll ignore it.

3.  Once the cloned note option is no longer available in the course of a patient encounter and physicians actually have to manually type out much of their encounter notes, patients will wonder why their docs are spending even MORE time staring at the computer screens and less time talking to them.

4. As clinic work flows get even more gummed up and waiting lists expand, outfits like National Government Services will announce that it will deny payment for documented medical services that are not provided in a timely manner. 

Silly you say?  Think again.

"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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One outcome of the Disease Management Care Blogs authorship of this manuscript that questioned the merits of the electronic health record (EHR) was an enduring belief that these systems didnt save money. The DMCB doubted that it would increase provider efficiency, decrease avoidable complications, reduce duplicative testing or increase quality. Its best educated guess was that the impact on overall health care costs was neutral.

According to six members of the United States Senate, the DMCB was wrong. They say the EHR may waste money and increase health care costs.

Thats among the conclusions of Senators Thune (R-S.D), Alexander (R-TN), Roberts (R-KAN), Burr (R-NC), Coburn (R-OK) and Enzi (R-WY) in their just-released report "Reboot: Re-examining the Strategies Needed to Successfully Adopt Health IT."

They point to the phenomenon of "code creep," which can result from using EHRs to document more extensive patient histories and physical examinations that, in turn, are used to justify an "upcoded" and theore richer bill with a higher payment.  In addition, the Senators point to research that suggests code creep can be linked to an increased ordering of clinical testing and services.  Last but not least, they point out that once an incorrect diagnosis enters the EHR, it is practically impossible to delete it, leading subsequent providers to mistakenly believe it is still active.

And to add insult to injury, Reboot describes the response of a "CMS official" who was asked about the above concerns.  The answer was that it would take years for the Agency to better understand the phenomenon.

The DMCBs take?

Closer examination of the Senators report shows that much of the cost concerns are based on lay media reporting instead of any peer reviewed studies.  That being said, there may be merit to the idea that EHRs can game billing systems.  It warrants further research.

Is partisanship playing a role?  The DMCB cant deny its a factor, but the same underlying motivation may be underlying CMSs unwillingness to do anything to diminish the Democrats health orm "branding."

Last but not least, the Agencys guess that it would take "years" to examine the concern is overly optimistic.  There are outside analytic/research outfits that can do a faster, better and cheaper job of coming up with an answer. 

The Senators and the U.S. taxpaying public deserve to know if this is true.

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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