Lab Soft News

Do Physicians and Hospitals Want to Make Us Healthier?

A very fundamental issue was raised in a recent note in the HIStalk blog based on a comment from a reader. The topic under discussion is why hospitals and physicians are resisting the conversion to hospital EMRs. The theory being raised is that hospital executives avoid EMRs because they make hospital business operations more transparent and subject to outside scrutiny. Thrown into this conversation is also the idea that treating the sick is more lucrative than assisting the well. Below is the comment and response:

From HIPAAHound: “Re: interesting take on the resistance to electronic medical records [A Pound of Cure: The federal government is about to spend big on health-care IT. Too bad the medical industry has a vested interest in inefficiency]. I have to say I agree with much of this reasoning, most especially where HC costs are increased by for-profit insurance companies looking to avoid paying claims by constantly moving the target for approved claims, thus sending admin costs for providers sky high, and the avoidance of any mechanism which might expose any of these practices to the general public. I am amazed that these practices have not been exposed already in our debate over HC reform.”

Mr. HIStalk response: Bet on it: whoever has the most lobbyists wins. This Technology Review (MIT) article is hardly complimentary: it says healthcare could have already gone digital if it wanted to, but resists to keep its lucrative business model out of the public eye. It also hints an another truism: it takes a lot of sick people to keep the big bucks flowing, so there’s not much incentive to lose customers by making them healthier.

Here's a provocative quote from the A.Pound of Cure article by Andy Kessler linked to in the comment above:

An even bigger threat to the sickness industry's business model is that by allowing automated tracking of patients over time, electronic health records would set the stage for early detection and preventive medicine. Currently, the entire industry is organized around treating sickness, rather than keeping people healthy in the first place. Three-quarters of health-care spending is devoted to chronic care, but the National Cancer Institute and the Centers for Disease Control and Prevention allot just 12 percent of their budgets to research on early detection. Moreover, the payment system is structured around reimbursement for treatment rather than prevention.

I generally concur that physicians and hospitals are most oriented to, and comfortable with, the treatment of disease and not the promotion of wellness. This is largely the result of physician training and the fact that our healthcare reimbursement system does not provide compensation for predictive and preventive medicine or wellness. I do not subscribe to the idea that hospital execs avoid computerization to "keep [their] business model out of the public eye." The business side of hospitals has been highly automated for decades. It is primarily the clinical side of hospital operations that has been resistant to automation and EMR deployment. This is largely the result of factors such as the inadequate outdated computer systems available in the market. resistance on the part of physicians to the shifting clerical duties to them, and failure on the part of physicians to embrace a standardized nomenclature for describing clinical observations and events.

Want a Job at the Cleveland Clinic?: Smokers Need Not Apply

I am generally supportive of anti-smoking legislation and rules. However, I have a feeling that we may be approaching a point where the rights of smokers are being seriously trampled. After all, smokers at work are already relegated to practicing their vice outdoors so second-hand smoke ceases to be a problem for the non-addicted. The Cleveland Clinic has now taken the step of refusing to even hire smokers. The details of this plan are presented in what appears to be a personal message posted on the web from Dr. Delos Cosgrove, Chief Executive Officer and President of the Cleveland Clinic (see: A Message About Smoking). Below is an excerpt from it with boldface emphasis mine:

While we are on the topic of smoking, I understand that there are differences of opinion about our recently announced policy to stop hiring smokers as of September 1st. Many people have told me that they totally agree with the idea. I have also seen and heard comments that what we are doing is discriminatory....Some have questioned the wisdom of our new hiring policy....But we are not the first organization to implement such a policy.The World Health Organization, American Cancer Society and more than 6,000 companies across the country have adopted similar policies in an effort to promote a healthy workplace. It's a growing trend; one that will likely keep gaining momentum....Some also have claimed that our new policy is not really about health, but about saving money....First, with our new policy, any applicant who fails the nicotine screening will be referred to a free tobacco cessation program that we pay for. Those who are successful in quitting will be encouraged to reapply after 90 days....We also are committed to taking a lead role in shifting the national focus from "sick" care to "health" care. As a true "health care" provider, we must create a culture of wellness that permeates the entire institution, from the care we provide, to our physical environment, to the food we offer, and yes, even to our employees.....Secondly, no one can deny the staggering cost smoking places on society. The U.S. Centers for Disease Control and Prevention estimates that smoking costs more than $75 billion annually in direct and indirect medical costs, and that businesses lose approximately $3,400 each year for every employee who uses tobacco because of increases in health costs and decreases in productivity related to smoking breaks....While current employees will not be tested, I encourage any employee who smokes to please consider enrolling in a tobacco-cessation class.

I suspect that the Cleveland Clinic would not have pursued a hiring policy that bars smokers unless they were convinced that it would withstand a legal challenge. Note that he cites other organizations that have employed a similar policy. I further suspect that legal issues may have been the reason that they decided not to fire existing employees who smoke. To do so would have made the new policy retroactive, which may have been grounds for legal action.

For me, the most interesting point in the rationale for barring smokers as employees is the following statement: We also are committed to taking a lead role in shifting the national focus from "sick" care to "health" care. I strongly believe in this concept and have published a number of previous notes about wellness versus the classic disease model (see: Wellness, Preventive Medicine, and the Classic Disease Model, Moving LISs Toward Greater Support for Preventive and Predictive Medicine, The Relationship Between Predictive and Preventive Medicine, How Predictive/Preventive Medicine Will Change Healthcare Delivery and the IT That Drives It). It's refreshing to see a large health system taking positive steps in this direction.

The PHR as a Tool to Enable Consumers to Take Responsibility for Their Own Health

Healthcare consumers need to take more responsibility for their own health, particularly to avoid or ameliorate chronic diseases such as obesity, diabetes, and heart disease. They also need access to the proper tools to achieve this goal. Tethered personal health records (PHRs) enable the transfer of critical health data from hospital and office EMRs to consumer-controlled records. With the exception of some health systems like Kaiser Permanente and the Cleveland Clinic, most providers have not been quick to endorse tethered PHRs. John Moore, who blog over at Chilmark Research, suggests that Microsoft is pursuing an international strategy for its PHR, HealthVault (see: HealthVault’s International Strategy). This will presumably enable consumers to self-manage, to some degree, their chronic diseases and, in so doing, help to mitigate the rising cost of healthcare. Below is an excerpt from his note:

The key driver for all countries is not much different than what we are experiencing in the US.  All are looking to reduce their medical risk profile by providing citizens and physicians better tools to manage health.  Primary objectives include:

• Support telemedicine with device connectivity (HealthVault Connection Center).
• Provide mechanisms/systems/tools, via HealthVault, to allow citizens to better self-manage and where possible minimize chronic diseases.
• Proactively engage citizens in their health by providing them with access to their personal health information leading to better, healthier and more knowledgeable decisions and subsequently, behaviors.

...Finland currently has 90% of its physicians using an EMR, but like most countries Finland continues to see healthcare costs rise.  Therefore, Finland is now looking at HealthVault as a critical component to take their national healthcare system to another level with deeper, direct engagement of their citizens and thereby mitigate cost increases. (In theory this makes sense, but there is no conclusive evidence that indeed this will work. Today, most are going on faith.)

It's interesting that Finland enjoys a 90% acceptance rate among physicians for EMRs but continues to experience rising healthcare costs. My personal belief is that office and hospital EMRs, if well designed, will allow physicians to work smarter and more efficiently but will usually not reduce the cost of healthcare. The reason for this is the very high capital cost of computer purchase and maintenance, including high-priced computer support personnel. In addition, EMRs and LISs provide the opportunity to generate new hospital management reports and perform functions relating to patient safety, quality, and surveillance that were not previously available with manual systems.

As John points out, there is still no firm evidence that patient self-help (see: "Participatory Medicine" and Its Relationship to Clinical Lab Testing), enabled by PHRs, can reduce costs. Nevertheless, I believe that it's worth a try. The challenge with tethered PHR will be convincing/forcing hospitals and physician offices to replicate patient data to patient PHRs. Most office and hospital EMRs are not designed to perform this function. In addition, much of the clinical data in these systems is not organized or phrased in such a way that it can be understood by healthcare consumers. Finally, much of the effort and capital costs to achieve this end on the part of physicians and hospitals would not be compensated under current payment systems.

"Participatory Medicine" and Its Relationship to Clinical Lab Testing

We should encourage healthcare consumers to actively participate in their own healthcare. The web will be a very important factor in this process by providing access by consumers to sophisticated healthcare information. Web-based personal heath records (PHRs) constitute another key element in consumer self-care by providing them ready access to their electronic health records. Web sites that enable consumers to order lab tests for themselves (the so-called direct access testing or DAT sites) are another facet of this approach to healthcare. One can use Health 2.0 (see: Introduction to Health 2.0) to refer to consumer-directed healthcare but Kevin Kelly make reference to what may be a better term -- participatory medicine. Below is an excerpt from his web site describing his involvement in this area (see: Journal of Participatory Medicine):

I've long been interested in medical self-care. The idea of patients taking responsibility of their own health and healing seems to me to be essential in the long run. [My web site] Quantified Self was started in part to collect a certain kind of tool that... might give you data which could be used to maintain or improve your health. Data measurement is only one way to improve your health, and it should certainly not be the only way. The main thing is that health is your job, and doctors and hospitals are your assistants and advisors, but to live this way requires a lot of education, skills, and support. I'm not the only person to head in this direction and for the past three decades a large number of dedicated doctors, public health agents, self-care journalists, and patient activists have been working on all kinds of ways to increase the role of informed patients. The newest channel in this effort is the launch of a peer-reviewed science journal dedicated to research in the field of "participatory medicine" -- as in patient participant. (Sometimes labeled Health 2.0) 

There is a important link between direct access testing (DAT) and PHRs. Some of the web sites offering DAT services provide access to a free on-line PHR. This service originated back to the days when tethered PHRs such as HealthVault had not yet been offered. I think that tethered PHRs will ultimately triumph over the untethered ones because they will contain both "official" health records generated in physician offices and hospitals as well as data entered into the record by the consumer himself or at his direction. DAT lab test results would fall into this latter category. Direct access lab testing enables the consumer to compare self-ordered test results with those generated in an office or hospital setting. In this way, the consumer can monitor the status of his health or chronic diseases at more frequent intervals than may be available during office or hospital visits. Such self-monitoring by lab testing goes to the heart of participatory medicine.

The Inclusion of Molecular Diagnostic Testing in Comparative Effectiveness Studies

I have made the point in previous notes that clinical lab testing, particularly molecular diagnostics, will comprise a key component of most comparative effectiveness research (CER). See, for example, the following: Comparative Effectiveness, Healthcare Cost Reduction, and Virtual Decision Trees; A Look at Deloitte's Healthcare Reform Pyramid: A Strategy for Reducing Costs; Moving Resources from the Therapeutic to the Diagnostic Silo; Biomarkers Used to Assess Treatment Efficacy. I suspect that most lab professionals assume that this same conclusion will be reached quickly by most comparative effectiveness researchers. Nevertheless, I was encouraged that the Association for Molecular Pathology (AMP) took advantage of the surge in CER funds to submit a letter to the Federal Coordinating Council for Comparative Effectiveness Research to make this very point (see: AMP urges inclusion of molecular diagnostic tests in comparative effectiveness research). Below is an excerpt from the article describing this letter:

The AMP letter recommends the development of a model process for CER regarding clinical laboratory tests. This model should include the creation of a panel of experts consisting of physicians and scientists, including laboratorians with molecular diagnostics expertise, economists, and reimbursement specialists; the creation of an electronic clearinghouse for information on CER projects similar to clinicaltrials.gov; the development and adoption of standards for the collection and storage of data from genetic testing laboratories in order to facilitate interoperability among databases; and a requirement that data from technologies and tests being assessed be generated from CLIA-, CAP-, ISO-, or FDA- certified institutions. Additionally, AMP wrote that in order to routinely incorporate information that relates patient outcomes to genetic variations into clinical care, there is a need to jointly fund large, carefully designed comparative effectiveness trials for molecular tests with observational comparative effectiveness studies that complement the randomized controlled trials by including patients who do not necessarily meet the inclusion criteria for traditional prospective trials.

For the sake of efficiency, let me distill from this article the key recommendations made by AMP retarding all comparative effectiveness research (CER) going forward:

• Development of a model process for CER regarding clinical laboratory tests
• Creation of an electronic clearinghouse for information on CER projects 
• Development and adoption of standards for the collection and storage of data from genetic testing laboratories
• Requirement that data for studies be generated by CLIA-, CAP-, ISO-, or FDA- certified labs
• Need to fund comparative effectiveness trials with observational comparative effectiveness studies that complement the randomized controlled trials

I personally find all of these recommendation eminently reasonable. I believe that there are a number of parallels between evidence-based medicine (EBM) and comparative effectiveness research (CER). I have been critical about EBM research in the past (see, for example, Flaws in Evidence-Based Medicine). Part of my criticism of EBM studies, and perhaps of CER of the future, is that they have taken too long to perform and established an overly rigid a set of conditions such that their results have not been generally applicable in clinical practice and thus frequently ignored. The recommendations of AMP about future CER such as the use of a model process, the establishment of an electronic clearing house on the web, and the need for observational studies can help to ameliorate some of these problems.

The Link Between Healthcare Reform and Post-Graduate Medical Training

Politicians and pundits have been stressing over the years the need for more primary care physicians. It's clear that this group of professionals fills a very important niche in our healthcare system, providing office care and coordinating referrals to medical specialists when necessary. By the way, such coordination is critical for the well-being of patients and inadequately, or not at all, compensated. It's time to launch a serious dialogue about the link between healthcare reform and post-graduate medical eduction with particular emphasis on the training of primary care physicians. A recent article is a good place to start (see: What Medical Education Has to Do With Health Reform). Below is an excerpt from the article with boldface emphasis mine:

Medicare spends $9 billion a year paying for the medical residencies where doctors get their clinical training. That training needs to change as part of the nation’s big health-reform push, argued a report...from MedPAC [Medical Payment Advisory Commission], the commission that advises Congress on Medicare. The report looked broadly at health-system reform, touching on a number of issues we’ve been hearing a lot about lately — the way Medicare pays doctors for volume rather than quality, for example, and how private insurers in the Medicare Advantage program are paid more than traditional Medicare programs. But we haven’t heard so much about how medical education fits in....Specifically, the report cited “the relative lack of formal training and experience in multidisciplinary teamwork, cost awareness in clinical decision making, comprehensive health information technology, and patient care in ambulatory settings.” More generally, the report noted, medical residencies are largely based in hospitals. That gives doctors great training in treating acutely ill, hospitalized patients, but doesn’t do so much to teach them to treat patients in outpatient clinic, where primary care docs do much of their work — and where key targets for reform, such as better management of chronically ill patients, will occur. MedPAC said it will look at ways to shift the funding for medical residencies to more closely link doctor training to long-term health-reform goals.

At the present time, most residents are trained in academic medical centers or in community hospitals that have a relationship with an academic medical center. The sickest and most complicated patients gravitate to, directly or by referral, hospitals such as these. This patient flow occurs with good reason because these facilities frequently tend to offer the best care. Medical residents at academic medical centers can opt for training that emphasizes outpatient care rather than critical care. However, I suspect that the experience of most may be lacking in particular areas such as those emphasized in the article quoted above: multidisciplinary teamwork, cost awareness in clinical decision making, and the requirements of running a small business such as an office practice. I am not sure that our teaching hospitals can provide the physician training that is required for a reform agenda. It's a topic that badly needs additional discussion.

The Value of "One-Stop" Breast Cancer Clinics Confirmed in the U.K.

Important topics for the future of healthcare will be integrated diagnostics, the merger of pathology and radiology, and integrated diagnostic centers (IDCs). The latter are multidisciplinary, integrated clinics where patients can be referred for rapid and efficient diagnosis. It turns out that IDCs are called "one-stop" breast clinics in the UK and that they have achieved an admirable record of success there (see: Missed cancer diagnoses rare at ‘one-stop’ breast clinics). Below is an excerpt from an article about these facilities with boldface emphasis mine:

Missed breast cancer diagnoses are very rare among UK women discharged from one-stop symptomatic breast clinics, indicate reassuring findings published in the British Journal of Cancer. Patients with breast concerns may attend clinics with multidisciplinary teams (MDTs) offering “triple assessment” of clinical breast examination, mammography and/or ultrasound imaging, and where necessary, needle biopsy....To determine how often women attending these clinics are later diagnosed with breast cancer, the team reviewed data from 7004 patients who were discharged after initial assessment between 2001 and 2003. Over 36 months of follow-up, 29 patients were subsequently diagnosed with breast cancer, giving a symptomatic interval cancer rate of 0.9, 2.6, and 4.1 cases for the first, second, and third years, respectively. The researchers note that breast cancer diagnoses were most common in women aged 40–49 years who “present the greatest imaging and diagnostic challenge.” Multidisciplinary review indicated that, of the women with a subsequent breast cancer, 10 women experienced no delay in diagnosis, and seven experienced probable delay....This gave triple assessment by a MDT an overall diagnostic accuracy of 99.6% and a missed cancer rate of 1.7 cases per 1000 women discharged.

I enthusiastically support the notion of multidisciplinary diagnostic centers (one-stop breast clinics in the U.K.) staffed by multidisciplinary teams (MDTs). Such an approach seems particularly apt for what is described above as a "triple assessment" of breast masses. In a previous note, I had this to say about MDTs from the perspective of cancer diagnosis (Bootstrapping the Integration of Pathology and Radiology):

[T]he most successful current examples of such [integrated diagnostic] "centers" where heterogeneous groups of medical specialists collaborate are cancer hospitals. The unifying factor for such centers is that all of the various physicians working in them can focus on patients with a specific type of disease -- cancer. In a diagnostic center, all of the various specialists will collaborate on a set of processes in the healthcare delivery continuum: the diagnosis of disease, the assessment of disease prognosis based on the diagnosis, and the choice of therapy based on the nature of the diseased tissue or neoplasm.

Of great interest to me that the overall diagnostic accuracy for women aged 40-49 with a breast mass in U.K. one-stop centers was 99.6%. I find this diagnostic accuracy rate quite remarkable. This group of patients is described as "presenting the greatest imaging and diagnostic challenge" for breast cancer, presumably because of the high incidence of concomitant benign breast lesions in them. Such a high accuracy makes sense to me in the setting described using all available diagnostic techniques. All of these factors provide an opportunity for effective team management and seamless hand-offs in a short time span.

Microsoft's Amalga/HealthVault Strategy Becomes Obvious

John Moore, who blogs over at Chilmark Research, always presents EMR and PHR issues with great clarity and knowledge. He recently attended the Microsoft Connected Health Conference and posted a blog note about some of the impressions that he gained there (see: The Borg Lives in Healthcare). Below is an excerpt from his note concerning the strategy that he believes Microsoft in pursuing with regard to Amalga and HealthVault, with boldface emphasis mine:

To some extent, that is the impression I walk away with from my attendance at the Microsoft Connected Health Conference.  That indeed, Microsoft and its Health Solutions Group (HSG) has indeed been assimilated by the healthcare sector. Now this is not necessarily a bad thing for Microsoft or the broader market but it does signal some important changes within the organization and more broadly confirms the strategy implied in recent announcements.  Primary among them is Microsoft HSG’s migration from an early consumer-centric strategy to an enterprise strategy.  Yes, HSG will continue to stand behind the consumer’s right to their health data and the consumer’s right to share that data with whom the consumer deems appropriate... [N]o longer is Microsoft interested in drawing the consumer to HealthVault... [R]ather, Microsoft will go to market directly targeting large enterprises, currently providers, ideally selling them a combination package of Amalga UIS [Unified Intelligence System] and HealthVault as in the case of the recent New York Presbyterian announcement.

John is right on all counts but I can't say that any of this comes as a surprise to me. On September 30, 2008, I presented my view of the emerging Microsoft strategy (see: Some Clues About the Microsoft Healthcare IT Strategy). Here is an excerpt from that note:

Microsoft's healthcare strategy is more obvious to me at this time than that of Google and consists of at least the following...elements:

• Develop a hospital EMR with Amalga starting with selected alpha sites as noted ...above. The company will thus be able to determine whether their product is competitive in the U.S. market.
• Sign high-profile deals with major health systems...to offer the HealthVault PHR to patients served by these health systems.

I would like to take some credit for my predictions of nine months ago but I won't -- it was just too obvious. Microsoft's was faced with two options after it purchased the Amalga EMR: (1) sell hundreds of millions of dollars of EMR software to hospital executives with HealthVault as a dangling appendage; or (2) distribute HealthVault to consumers free of charge and with no reliable business model to generate revenue for the company. It was clear to me that Microsoft would be much more comfortable and accustomed, from a corporate culture perspective, to participating in power lunches with hospital executives than working with the more demanding and vocal healthcare consumers. For their part, hospital executive are also most comfortable with bulky, over-engineered software that takes months of training to use properly and may never work as expected. Any after all, this is the type of product that Microsoft surely knows how to deliver. No need to cite product names here.

Earning an MD Degree in Six Years to Reduce the Debt-Load of Medical Students

I was admitted to medical school without an undergraduate degree nearly 50 years ago. I had completed the obligatory courses for admission and the University of Michigan Medical School accepted me. Medical schools and professional medical associations are now under pressure to reduce the number of years required to obtain an M.D. because of the increasing debt-load of newly graduating physicians (see: AMA Looks to Put Brakes on Debt Load of Med Students). Below is an excerpt from this article with boldface emphasis mine:

Medical students who went into debt could figure on owing $126,714 in 2007 on average, up from $88,331 in 2000, according to the Association of American Medical Colleges. You can figure the debt tab has only gone up since then. Such statistics are being cited by American Medical Association as docs prepare for their [upcoming] confab in Chicago next week....Suggestions under consideration would take approval by powers greater than the AMA. They include providing tax deductibility for tuition and loans, and expanding state and federal scholarship opportunities. But another cost-cutting approach is investigating ways to reduce the length of medical schooling—perhaps through competency-based curriculums, or through combined B.A./M.D. programs. Some schools already offer a variety of such combination programs, though only a handful actually shorten the total length of training. For those that normally don’t worry about the school loans carried by docs, remember that the med school debt load can have broader implications. It’s one of the most common reasons given for problems like the shortage of physicians and the skewing of medical professionals toward specialty practices.

How about consideration of programs to reduce the number of years required to obtain an M.D.? I personally believe that developing a combined B.A./M.D. degree programs is the wrong approach. This was attempted in the past at the University of Michigan Medical School -- the six-year program was called Inteflex and was ultimately abandoned (see: Be flexible -- Eliminating Inteflex would limit students' options). One of the reasons for its demise was that the 18-year-olds admitted to the program were being guaranteed admission to medical school after completion of their undergraduate courses. For many and because the pressure for admission to medical school was eliminated, they decided to take it easy, often receiving their degrees in eight or more years. Many also decided belatedly that the medical career path was not suitable for them.

Here's my modest proposal for shortening the number of years to earn an M.D. without spending a dime and without burdening medical school deans and curriculum committees with additional work. In order to understand this proposal, you need to understand that for most medical schools, the fourth year studies are comprised mainly, or even totally, of electives rather than mandatory courses.

• Medical schools should begin to accept students, as in former years, after three years if they have fulfilled all of their undergraduate course requirements. If this is impossible given the number of such prerequisites, this number should be reduced such that it is possible for most applicants to quality for the new program.
• On a selective basis, medical school should allow some students to skip their fourth year and graduate in three. This should only be an option for the most mature students who have amply demonstrated their ability to function well as they pursue their post-graduate medical training.

The likelihood of such a plan being adopted is probably slim. It will require minimal planning and, after all, medical school deans are compensated for their curricular planning expertise. The deans and presidents of undergraduate institutions would also probably oppose such a plan as they did when I pursued it many years ago. They will argue that physicians need the broader liberal arts background. However, I am not convinced that one more year of undergraduate studies will achieve this goal.