Getting Digital - The Movement is Gaining Momentum

I've recently read a couple of articles about using email with patients. One, by Kevin Pho (aka KevinMD), acknowledges the potential benefits to both patient and physician, but comes down on the side of the "cons" outweighing the "pros". The Wall Street Journal article from earlier this year presents both sides of the debate, with Joseph Kvedar being for the use of email, and Sam Bierstock being against it.

Over the last year to eighteen months I've increasingly been using secure email with my patients. Not to diagnose or assess new symptoms, rather for the more prosaic aspects of patient follow up and monitoring. Today in my clinic I scribbled my email address on a piece of paper and gave it to a patient. My aim was simple, I wanted to make his passage though the system as efficient and effective as possible, so I told him to email me once he had had his scan. My caveat was that once I've seen the scan we could then speak on the phone and decide on the most appropriate next steps. There was an expression of happy bewilderment on his face.

Similarly I am increasingly getting patients to monitor their symptoms, and progress, online. Peak flow measurement, symptoms of breathlessness, exercise tolerance and even medication adherence can all be easily tracked and monitored in a secure patient portal environment. I've found that if you as the physician ask your patients to do this the majority actually do.

What I've also found is that this doesn't replace the doctor patient consultation (well, occasionally it does when a patient communicates that they feel well and don't want to see me), rather it enhances it and makes the discussion more relevant and objective.

I'm baffled why so many of my colleagues are still so vehemently opposed to harnessing digital technology to enhance their patients' experiences. Medicine really is the last bastion of doing things the way we've always done things. If I were to make one prediction for the coming few years it would be that there will be a communication revolution in healthcare (much like happened to banking and finance 20 years ago). And I'm not just talking about doctor-patient communication, but doctor-doctor communication and information sharing. The seeds are sown with meaningful use stage 2 criteria and I do believe that if you don't get on board and embrace a new way of doing things you will get left behind.

Health Checks Are Bad For You? You Can't Be Serious!

Many of you may have read the recent news articles quoting the findings from a published review by the Cochrane Collaboration. The overall conclusion was that hat general health checks in adults do not reduce illness or death, and in fact may cause harm. On the face of it the findings seem counter intuitive to the modern practice of preventive medicine so I thought it was well worth the time and effort to have a look at the research paper and make my own mind up. The write up of the research study was published in the BMJ, but the full analysis, including some of the data not presented in the BMJ article, is available from the Cochrane Library.

The Cochrane Collaboration of researchers is a well respected group, who do a number of systematic reviews of published research to try and get to a "global truth" about a particular question. In essence what they did with this piece of work was look back at published scientific articles that specifically examined the impact of health checks on patient outcomes and pooled all of the results together to give an overview of the effect. In a way its a bit like Trip Advisor, but for research that has already been published.

The first thing that struck me when reading the BMJ paper was that the previously published research articles included in this overall review were really quite old. Eleven of the fourteen previous studies used for the review were conducted before 1990, with the oldest being from 1963. In fact six of the fourteen are from the 1960s. The world has changed a great deal in the intervening 50 years, and so has the practice of medicine. To state that health checks have no discernible benefits for participants, and may in fact cause harm, and to base this on studies from the 1960s is not logical, and could potentially be seen as being misleading.

As well as this the researchers did not analyze previously published research studies that looked at single-intervention health checks. The sort of things we are talking about are studies that have looked at the benefits of screening for specific diseases or conditions like prostate cancer, COPD or colon cancer. This again makes very little sense as there is a lot of evidence to support the impact of specific screening tests on morbidity and mortality.

The final aspect of the study selection methods that I found rather curious was the fact that the authors did not include research on health checks conducted on individuals who were over the age of 65. Their justification for this was that the published research on health checks for older adults often included additional interventions such as falls prevention and medication reviews. This just doesn't make any sense. Its like saying I'm only going to look at Trip Advisor ratings from people who rate hotels...if they also rate restaurants and holiday rentals then I am going to ignore what they have to say.

With these inconsistencies and methodological issues I leave it up to you to decide whether the conclusions reached by the authors of this piece of research are valid or not. My opinion is that annual health checks are a valuable and important part of a proactive approach to population health management. The NHS in the UK and Medicare in the US have definitely got the right approach with their fully covered health and wellness visits....long may this common sense prevail!

ROI for Patient Engagement

The recent publication by the CDC on the prevalence of COPD (chronic obstructive pulmonary disease) is fascinating. Not just because it maps out the burden of this largely preventable disease within our country, but because it highlights to opportunities for population health management and patient engagement.

On average the prevalence of COPD in adults across the United States is 6.6%. In other worlds, one in every fifteen individuals had this disease. Now this is not quite as big an issue as diabetes within our society, but it is not far off, and the impact it has on healthcare delivery and costs is huge.

Not surprisingly the prevalence of COPD increases with age. This is because of the natural history of lung function decline. Once an individual is operating at about a third of their predicted lung capacity they become frequent users of healthcare resources, especially expensive emergency treatment

Take a population of five thousand individuals, the minimum number of patients an accountable care organization can be responsible for. Using the national average figures it is likely that 330 will have COPD to some degree of severity. In addition, according to the research 17.7% (or in this case 58) of these individuals will require hospitalization or review in the ER a year. Data from the American Lung Association suggests that the cost of such an admission is in the region of $20,000 per visit.

Undoubtedly some of these emergency admissions are totally warranted on clinical grounds, but as a pulmonologist I know that some are completely avoidable. There are two facets to this “avoidability”; the first is the fact that many (the exact numbers are rather hazy) patients do not take their prescribed medications as intended by their physicians. This non-adherence is often borne out of ignorance, rather than a conscious decision by individuals to be difficult or recalcitrant! Better education and the co-creation between doctor and patient of a self-management plans can have a dramatic effect here. The second issue is that we physicians often catch deteriorating patients late. Their exacerbation is in full swing and there is very little option but to transfer them to an emergency care establishment.

The solution to this last issue is a little more difficult. Many of my colleagues would day that there is nothing we can do. If a patient shows up with a severe exacerbation of their airways disease (or any other chronic condition for that matter), “how were we to know?”. This is true, however, it shouldn’t be the case. We now have the technology to keep in touch with our patients on a regular basis. I’m not even talking about sophisticated telemonitoring equipment here either. Secure email, text messaging, online symptom tracking should all be elements of a 21^st century physicians kit bag.

Just look at the savings that could be achieved by being more proactive. If just one exacerbation of COPD requiring hospitalization were prevented a year through this more proactive patient engagement approach that would be something, but I suspect that even in a 5,000 patient practice this number would be ten or twelve. And that’s just COPD…what about diabetes and congestive cardiac failure?

Patient Access to Online Clinical records and Healthcare Utilization

There's been a lot of discussion about the recently published JAMA article on the association between the use of online Personal Health Records (PHRs) and utilization of healthcare services. Most of what I've read has been along the lines of "how can this be true...surely using this sort of technology to better engage patients should reduce overall healthcare utilization?". Indeed that was my first thought. Clearly a scholarly article published in the Journal of the American Medical Association should not be taken lightly in terms of its findings, however, looking at what was done and what the actual results of the investigation were is always a good thing before making a judgement.

The first thing that should be noted is that this was a "retrospective" study. In other words the authors looked back at data that had already been collected between 2005 and 2010. Now this isn't necessarily a bad thing, but inevitably in these situations there are details that one would want to know (for example in this case details about what the extra office visits and calls observed in the group who accessed the PHR during the study period were for) that just aren't available. So in this case although the researchers demonstrated that the group who had access to their own medical information via the Kaiser PHR appeared to utilize more services we have very little idea what the focus of this additional utilization was. It is completely feasible that this group had a better understanding of their own health by virtue of having access to their records and were therefore more proactive in seeking advice early around preventive health and early diagnosis of symptoms.

The second point is that because of its retrospective design the research did not have a control group of similar individuals who did not have access to the PHR to compare to. Because the Kaiser integrated delivery system in Colorado is large the researchers were able to look at healthcare utilization data from individuals who did not access the PHR system, however this group were significantly different in a number of demographic attributes to the individuals who accessed the PHR during the study period. The non-users were younger, more likely to be male and had fewer chronic diseases that PHR users. The researchers get around this by using a statistical technique called "propensity scoring". In essence this matches individuals in both groups based on particular characteristics. Now as far as I can see from reading the paper, the only characteristics used to do this propensity scoring were the year(s) of data collection and the historical number of baseline office visits individuals made. Although this approach allows for a better comparison between the two groups you cannot by any means say that the two groups were the same. This fact is demonstrated by looking at baseline ER visits between the groups; the group that did not access the PHR had almost 33% higher ER utilization that those that did, and this suggests that their approach to their own health and how they access services was fundamentally different from individuals who engaged with the PHR.

My final point is that even if one accepts that engagement with a PHR somehow drives greater utilization of services how does this translate in terms of patient outcomes? Unfortunately this data was not available to the researchers, but it is one that needs to be understood. In the brave new world of cost containment and outcome demonstration we have to understand whether the extra half an office visit per year per PHR user shown in this research study delivers value (the definition of which is cost divided by outcome) to the healthcare system as a whole.

Don't get me wrong, this article is not an attack on the authors or the research methodologies used in this piece of research. We need to better understand not only how to engage patients in an ongoing dialog about their health, but also what impact that increased engagement has on service delivery. This paper has framed some of those questions, and although not perfect has provided rich food for thought and discussion. It should not, however, tempt us to abandon driving better patient engagement, nor using technology to facilitate this.