It's Time to Practise Better Medicine

This article from @KathyKrostof on CBS got me thinking this week. Although as physicians we're no strangers to the art of complaining, it does appear that things are really getting strained out there on the front line. Talking to friends and colleagues from many different disciplines much of the frustration seems to stem from not being able to practise the sort of medicine we want to, and indeed signed up for when we first entered medical school. Too little time with our patients, over burdensome paperwork, a disjointed system where half the time we are in the dark as to what's happening with our patients outside of the office. I know I have to frequently spend significant amounts of time trying to piece together what's been happening with patients who see other specialists in different institutions; usually by wading through a disorderly pile of faxes or letters. This isn't medicine as it should be, this is fire fighting and disaster aversion. I am constantly amazed at how backward we have been, and to some extent continue to be, in how we practice medicine and deliver care.

This blog posting by @GertiTechBlog speaks volumes about the challenges faced by many of us, especially those working in primary care. And it is my feeling that the reason many physicians are feeling unhappy at the moment is not because they've fallen out of love with the practise of medicine, rather it is increasingly frustrating trying to do a good job.

Technology has transformed many aspects of our lives. It is sometimes hard to remember that we used to have to go to a travel agency to book a flight or a vacation, or go to a book store to buy something to read. Many of us now have complete control of our finances and bank accounts via the Internet and hardly ever have to visit a branch. Yet the practice of medicine has hardly changed during the time that this revolution has occurred in other areas of our lives. Why is this?

Part of the problem is undoubtedly the fact that as providers of care we have been extremely reticent to adopt new ways of doing things, preferring the status quo of the way its always been done. It wasn't a desire to practise better medicine that drove the uptake of electronic health records, it was the huge amounts of Federal incentives that made it happen. It really is very curious that it should take what is ostensibly a "bribe" from the government to do something positive, rather than taking it upon ourselves to enhance how we practise. Of course there is the debate that EHRs have not actually made the practise of medicine more efficient, cost effective or better...but that's a topic for another discussion!

Perhaps if we spent a little time looking at how other industries have developed and utilized technology over the past decade we could get some ideas on how we could improve what we do. I really do believe that the intelligent use of technology in our day-to-day interactions with patients and colleagues has the potential to improve how we feel about our jobs and also enhance our patients' satisfaction with the care we provide.

It's no secret that most major vendors of products and services have highly sophisticated customer retention and loyalty programs. They want to stay close to their customers, recommend other services that may interest them and find out what they think about what they've received to date. Now this is not a direct analogy with delivering medical care, but there are probably some aspects that still hold true. How difficult would it be for us to inquire from our patients how they are doing, what they thought of their last healthcare interaction and whether they were on track to reach the goals agreed on their last visit? Using traditional face-to-face interaction would probably prove quite difficult (or at least time consuming) for this, however, this is where technology can help and it is where the likes of Amazon, Expedia and Hilton, to name but a few, have excelled in driving loyalty and trust.

We need to think differently about how we deliver healthcare in the second decade of the twenty-first century. Storing information in an EHR is just the beginning, there are so many other ways we can interact and influence our patients in a positive fashion. Those of us who grasp this challenge, I believe, will drive better outcomes and greater value; two facets that are going to be integral to the future of healthcare.

nGage Health's patient timeline where all interactions with the healthcare system are graphically displayed for ease of review by both patient and provider.

Wearable and Cool

I've spent a lot of the last week reading reviews and watching videos from the Consumer Electronics Show (CES) in Las Vegas. Unfortunately I wasn't able to make it out west, but that didn't actually matter too much with the amount of commentary that was coming out of the show in pretty much real time. This was the first time that I can remember that I really felt like I was immersed in a "real world" event while physically being more than a thousand miles away. Now clearly it's not going to be quite the same as being there in person (canapés and a cocktail on your own isn't that much fun!), but the sheer depth and breadth of the commentary coming out of the event from people who were there was astounding.

It seemed from the outside that healthtech and wearable tech were big items at this years show, with companies big and small previewing their new offerings. This infographic from the organizers seems to confirm this, with these two areas coming in first and fourth in terms of volume of mentions on social media.

As an organization that harnesses data from wearable devices and apps, and makes this data usable for healthcare providers, this is obviously great news for us. It appears that there is growing interest in self-monitoring and quantification and it seems unlikely that the large tech companies would be putting in so much time and effort into creating new and improved devices if they didn't see a real market for them.

Having said this I have got he impression that the majority of the devices are variations on a theme; physical activity, sleep and nutrition.This discussion thread on the Digital Health group on LinkedIn started by @BillVick calls for more diverse offerings. I do tend to agree. Although the data from continuous monitoring of activity and sleep patterns is extremely valuable there are so many other parameters that would augment this data and provide real insight to both the individual and their provider of care.

Of course there is the gray area between what constitutes a medical device and what is a consumer product. Falling foul of the FDA is not something anyone wants to do, especially in the light of the recent 23AndMe episode. However, with the pace of change in the industry seemingly accelerating to "warp speed" I am sure it is not going to be long before a consumer will be able to measure and monitor pretty much any parameter that their physician can. With this I truly believe there will come great opportunities to improve the health of the population, reduce the cost of delivering healthcare and make sure our patients (read clients) are satisfied.

Example of how the nGage Health platform presents data from a population using different devices to track physical activity.  

Health Engine Optimization

I recently read this Wired article on search engine optimization (SEO) and how Google are potentially leveling the playing field by placing more emphasis on the value of the the content on a website. Rather than clever coding and tagging tricks that have traditionally been used to enhance a website's position in a search they are saying that it is the quality and relevance of the content that is going to dictate its position. You can't really say fairer than that you have to admit.

In a way an analogy can be drawn with healthcare and the need to optimize a process that for decades has functioned in a very nontransparent way. You become unwell, visit a doctor, get treated and (hopefully) get better. The process then repeats itself the next time illness strikes. This episodic approach is possibly fine (but not optimal) for relatively minor ailments, but as we age and the likelihood of developing chronic diseases increases, this approach often falls short of delivering quality care. By comparison with other developed countries the United States routinely languishes near the bottom for mortality from most chronic diseases. 

Healthcare reform may go some way to redressing this aberration (how the richest country with the most expensive healthcare system can consistently perform so poorly compared with other industrialized nations), but providers of care also have to critically examine how they deliver care. This I believe is where significant optimization can occur.

There is the dawning of recognition in the medical community that every episode of care does not necessarily need to be conducted in a face-to-face setting, or indeed happen in real time. But counteracting any significant change in how medicine is practiced are the perverse incentives associated with a fee for service model for remunerating providers. This is gradually changing, with greater numbers of physicians being employed by larger systems, opting to practice concierge style medicine, or participating in accountable care organizations. This will eventually mean the fee for service model won't be as big an influencer on behavior as it is today. 

As this change gathers momentum there will be an increasing need to modernize the way medicine is practiced, because provider remuneration will be based on outcomes and patient satisfaction, and not just episodes of care. This I believe is where technology comes in. As I mentioned, not all interactions need to be carried out face-to-face, and in fact some may even be better for not being face-to-face. This is not just telemedicine (although I am sure that it has a significant role to play in the future of healthcare) it's about utilizing technology to create an ongoing connection between provider and patient.

Imagine if providers had a dashboard that would give them access to regular, current data on, for example, diabetic patients' blood sugars, or an asthmatic patients' peak flow readings? They would be able to be proactive in managing these conditions both at the individual level, but also at the population level. The step change from the episodic reactive way of managing patients to one where there is a real opportunity to be proactive and predictive would surely improve outcomes, reduce costs and lead to greater patient satisfaction.  

This is not just a fantasy. It is happening in the here and now. At nGage Health we're creating solutions that allow providers to capture data from their patients (using health assessments and popular apps and devices) and merge that data with salient information from the EHR to generate a real-time population-wide dashboard, and we'd love to tell you more.   

nGage Health's Provider Dashboard for Population Health Management

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.