Proportional News Coverage - Skewing Health Perception

Our perception of health and risk is all wrong and instantly accessible media is one of the key reasons. The recent coverage locally in the Washington area demonstrates the point well. A quick Google search of "Metro Crash" in the news reveals a total of 6,132 results (no doubt this will increase over time). A tragedy occurred on the Washington DC Metro when one train collided with one car riding up and over the other. There were several fatalities (9 at the time of writing this post) and a range of injuries from severe to minor. Coverage in the hour long evening news on the night of the tragedy could be summarized as follows:

• Evening News Length: 60 Minutes
• Advertisements Time: ~20 mins
• Time dedicated to the Crash: 35 mins
• Time dedicated to remaining news: ~5 mins

This disproportionate level of attention skews our perception of risk. Anyone watching the news last night would find themselves focusing on the safety of the Metro system. A quick search for statistics (interestingly the Wiki Page on the Washington DC Metro's Security and Safety had already been updated with details of the latest crash!) reveals a list of accidents but no suggestion of significant problems or challenges facing this system. In fact the overwhelming commentary suggests "The DC Metro has a very good safety record". When compared to data on Traffic Fatality Rates for DC:

• Traffic's most recent data for 2007: 44 fatalities (US total fatalities 41,059)
• DC Metro 15 (subject to change based on the most recent crash) over the last 20 years

Healthcare is the same and our perception of risk is skewed based on media coverage and our own personal experiences. If the news media gave proportional coverage based on risk and causes of death it might look something like this

• Evening News Length: 60 Minutes
• Advertisements Time: ~20 mins
• Time dedicated to the Heart Failure and Cancer: 20 mins
• Time dedicated to Cerebrovascular Disease: 4 mins
• Time dedicated to remaining causes of death 6 mins
  

How can technology help - in this instance it appears not to be. The instant availability of news, our ability to blog and tweet the latest information and the way in which information can take on a life of its own (can anyone say Swine Flu H1N1). We need to filter information and it is the link to our clinician that helps provider that input and balance. Id be the first to encourage everyone to be their own primary care practitioner - in fact I said so last week but this has to be balanced with appropriate input from trained experienced professionals. There are a range of tools to help diagnose problems including some online symptom checkers and they have a place in the range of choices available to us. But this is not about replacing the education and experience of your clinical team. This is about supporting them with appropriate information.

In a recent discussion with a clinical colleague he was adamant that clinicians must use technology and clinical systems to be able to deliver better and safer care. I agree that technology must be used to help support the decision making - in fact I think it is as much about information as it is about technology. Technology just helps bring the information closer to the decision making point. This can be as simple as patients searching for information and bringing in printed material to the consultation (I know to some clinicians this is their nightmare but I remain convinced that there is no stronger more dedicated advocate for the successful outcome than the patient themselves).

But getting to this data and providing it not only in digital form but better yet in a form that can be consumed and processed by electronic systems takes this to the next level. Linking this information to the full Healthstory allows for some automated processing and relevance mark up that will help in filtering useful from distracting data.

Personal health management includes the capture of information and the intelligent sharing of this between the patient, the clinician and clinical systems. This is a team approach and the team will help balance the perception of risk. Finding balance is one of the keys to navigating through life. Have you found balance and if so how. What's your perception of coverage, risk and the media coverage distorting our perception of risk.

AHRQ Patient Videos - Become your Own Primary Care Provider

In an interesting use of technology and social media AHRQ (Agency for Healthcare Research and Quality) have a series of public service announcements directed at patients encouraging them to ask more questions before during and after your medical appointment and in one case have a song and dance spot (wmv file) encouraging patient participation and asking questions:

DOCTOR (spoken): Any questions?
PATIENT (spoken): No.
DOCTOR: You know...
DOCTOR: (begins singing): We're not magicians, we can't read your mind!
BACKGROUND (singing): Read your mind!

Fun video - important points. Questions are the answer. As the AHRQ group puts it you play a critical role in improving your own healthcare and making wise medical decisions. As I heard recently in one presentation - we all need to become our own Primary Care Provider - managing our own healthcare and understanding the choices available to us. As was pointed out in one of the videos - we spend more time asking questions when we order food or buy a cell phone than we do when we go meet out doctor for a check up or clinical problem. No doubt some of this is time challenges faced in busy clinical practices and a degree of intimidation that persists in relation to patients and their relationship with their clinical provider.

Part of the process must include bringing information to the appointment and referring to it as well as extracting as much information both verbally but more importantly in electronic form from the clinical visit. Asking for a copy of your medical record should be a standard request - over time this may become a more electronic activity and even include requests that ask for the record to be sent digitally to your own Personal Health Record. But for now a paper print out is already an improvement and will allow a better understanding of the appointment. There is no better advocate for a successful outcome that you and your family members and oftentimes more time available for you to focus on doing the research on your own condition and understanding of the choices available if not the personal choice to be made. The AHRQ site gives some guidance on questions to ask here - extensive list and not all questions are necessary for all interactions but a good starting point. It's your health - start taking care of it and participating in the process actively not as passive observer.

Had good or bad experiences share them here - maybe your doctor actually volunteers your record and discussion or maybe your clinical office refuses to provide you with all your records. Whatever your experience I'd love to hear from you.

Interoperability and Data Entry - There are Solutions

This piece on the Syleum blog analyzing data and effective communication on "The Data Model that Nearly Killed me" makes for interesting reading

During the last week of January 2009 a faulty electronic, networked, health information data model nearly killed me despite its vaunted status as a component of two state-of-the-art, health information systems at two of the world’s most advanced medical facilities.

It does not come as a surprise given the complexity of medical information and the exponential growth in that data that keeping all this information correct, connected and up to date. In fact there was a veritable uproar created with the this posting by ePatinetDave - Imagine someone had been managing your data, and then you looked" (also this post). Not surprising to those of us who have looked at our own data for the last several years, myself included but quite shocking to most folks who for that period of time have been entrusting their data to others expecting it to contain accurate and appropriate content.

The sharing of information across systems just doesn't exist and I've talked about his before (here, here and here) and it's frustrating as hell to everyone involved. The patient ends up repeating information multiple times

The nurse who escorts me into urgent care asks me for my doctor’s name. I tell her my allergist’s name. The nurse argues that she wants to know the name of my primary care physician. Of course, that information is in my electronic medical record that she can readily access. The nurse next requests me to relate my medical history - which information is available in the electronic record. Next, an attending physician asks for my doctor’s name, no, not my allergist, my internist, and please relate my medical history. Never mind that (a) I provided this information to the nurse only moments ago, (b) I can barely breath, (c) I have horrible pain in my lungs, (d) I have a high fever, and (e) the requested data already is in my electronic health record.

In fact this is all in one office let alone sharing between offices....! This goes on with multiple interactions being documented next in the Allergists offices, then in the ambulance and then in the ER

I was in ER for 20 hours before being admitted to the intensive care unit (ICU) where I spent another 28 hours. Throughout my stay, I was hooked to network attached monitors that incessantly sounded alarms to which no one responded. I was asked 11 times to repeat my medical history, medication, and allergies to as many different medical professionals. I was seen by seven doctors each of whom asked me similar questions. Five doctors were never to be seen again. All doctors mumbled something about putting their findings into the hospital’s electronic records system - most did not according to ICU nurses. No one read my allergist’s detailed report about my condition and health history.

Then some heroic efforts to enter and capture this in electronic form

One heroic medical professional, the first nurse I met in ICU, worked to create a consistent record of my condition, allergies, and medications in the hospital’s electronic health information system. She spent over one hour searching for previously entered data, correcting errors, and moving or reentering data.

The review is a damning indictment of "the system" and it matters not which one it is

Medical personnel at urgent care and the hospital who interacted with me all used a version of the same electronic health information system (the “system”). It became clear that everyone was fighting that system. Indeed, they wasted between 40% and 60% of their time making the system do something useful for them. The system kept everyone from fulfilling their duties - the health information system did not help medical professionals perform their duties.

Fixing the underlying data model and the systems that we use to interact with these systems must be on the critical path. Spending millions of stimulus dollars on systems that "wasted between 40 - 60% of clinician time" is not going to fix the problem. Unfortunately fixing the data model is a challenging problem as this is a moving target in medicine. But fixing the capture of this information is not - there are time related challenges but existing infrastructure - dictation and transcription used in conjunction with technology: speech understanding, CDA and the healthstory interchange format and most importantly knowledge based workers: medical editors can help facilitate this process and at least relieve the burden of data entry from the time pressured clinical staff who want to (and used to) focus on the patient and their care rather than on the system and data capture.

Why Participating in Blogs is Important

I had the privilege of meeting e-PatientDave at the TEPR conference this week. He was there to bring the patient's views to this conference - wow - that's a novel thought! Getting patient input at a conference on healthcare......this does not happen often enough. It was a commanding performance and one that should have been videoed and then youtubed but I think he has this in the plan based on what I read.

He has his own blog(s) e-PatientDave and is of course on twitter and is an advocate for the inclusion on the patient in the care process (whew - two eureka moments in a single post!). He made many compelling points, delivered an emotional and riveting diary of his incidental finding of an especially aggressive form of Renal Cell Carcinoma that he fought and won. He joined an impromptu tweetup at the evening reception and continued to engage throughout the conference. Much of what he does is on his own coin and time and done with the attitude that given the history every second is a bonus.

A post from last month on why he loves participating in blogs and healthcare is descriptive and a great study of the relevance of this media to our future.....if you are not involved in this media the world is going to pass you by. This post linked to Paul Levy's "Running a Hospital blog that is definitely leading the crowd in communication and openness. He had cited the news of the day on "Check Lists" - I talked about this last year in this post - Simple things save lives crediting Peter Pronovost and congratulating him on his recognition as a newly inducted fellowship. There was a great article in the New Yorker titled "The Checklist" that detailed the concepts and the amazing results

Social media power. Connecting and engaging everyone. If you aren't on board you should be. Do you agree or is this just more "stuff" to distract us form delivering care - you tell me.

There are so many ways to participate and here are some of mine (it's horses for courses - pick the media you like):

Twitter
Technorati
RSS Feed - Speech Understanding
RSS Feed - Navigating Healthcare
Linked-In
Plaxo
Facebook
Digg
del.icio.us
Follow me on Twitter
DM Reply on the Twitter

Americans Pay More for Healthcare - But Why?

The McKinsey report "Why Americans Pay more for health care" (free registration required for access to full report) provides useful insights into the spending patterns and some of the underlying reasons for the high cost of health care in the US

While the higher costs is expected in part due to the wealth of the country:

Across the world, richer countries generally spend a disproportionate share of their income on health care. In the language of economics, it is a “superior good.” Just as wealthier people might spend a larger proportion of their income to buy bigger homes or homes in better neighborhoods, wealthier countries tend to spend more on health care.

Despite taking account of this the US spends some $650 Billion more than might be inferred from its wealth. As for the where this spending goes

The research also pinpoints where that extra spending goes. Roughly two-thirds of it pays for outpatient care, including visits to physicians, same-day hospital treatment, and emergency-room care. The next-largest contributors to the extra spending are drugs and administration and insurance.

But do we receive value for money - not based on outcome measures as compared to other OECD countries where we lag in many areas (more here and here where the US ranked last in a group of 19 countries). The report looks at possible reasons for the additional costs including the possibility that a less healthy population would mean higher treatment costs........survey said no.

So where does this additional expenditure go? Two thirds of this goes to outpatient care and while the US is doing well by shifting care and cost from in patient treatment to outpatient (and the legacy of President Bush's community clinic outreach has been a positive component of that as detailed here) this has actually added to the cost of health care in the US because of much higher utilization. Unfortunately not only was the utilization up but so too was the cost visit in part due to increasing use of expensive diagnostic testing (CT and MRI's being major contributors). The system is structured in such a way as to incentivize this type of care with the delivery of more services offered that are more expensive.

After outpatient care the next highest contributor is pharmaceuticals and not because of increased usage of drugs but because the mix is of more expensive and and the higher cost of drugs in the US

the price of a statistically average pill is 118 percent higher than that of its OECD equivalents

Even taking account for the possible explanation that the US pays more for a "superior product" and the high prices that subsidize the R&D for the rest of the world this still does not explain the large differential

But none of these factors, by itself, can explain the gap between the price of drugs in the United States and the rest of the OECD. When we adjust for US wealth, we find that the country’s branded-drug prices should carry a premium of some 30 percent, not 77 percent for branded small-molecule drugs.

Finally administration and insurance costs are the third highest but although these costs are significantly higher than other countries, the good news it

.....we find that given the structure of the US system, its administrative costs are actually $19 billion less than expected, suggesting that payers have had some success in restraining costs

The possible solutions are wide and varied but must involve all the stakeholders. Despite the high spend the US continues to lag behind in the general health of the population and as such "reformers should therefore focus on the preventative efforts" which represent a potential big win. Community clinics as supported by President Bush's administration are one such effort. In addition the consumer must be more engaged and informed and this requires the sharing of health care information that is structured so as to provide real information and not just make the medical haystack bigger. Technology plays an important part in the sharing of data and the ability to structure and make it available quickly and in meaningful ways to allow decisions and choices to be made.

Healthcare CIO's Grappling with EMR Adoption

SearchCIO online magazine ran an article on EMR adoption that made for interesting reading:

When patients, physicians and payers embrace the electronic health record (EHR), life will be different in pretty amazing ways.....For the first time, patients will be treated by a personal team of clinicians. When a new drug for hypertension comes on the market, all patients (not just Nobel laureates like James Watson) will be able to map their genotypes and phenotypes to that medication to determine if it's right for them. Hospitals will be held to the "perfect care" standard -- the elimination of all medical errors in instances of preventable harm.

Wow! But the problem is we are nowhere near the level of adoption necessary to achieve these kinds of advances and the barriers to adoption remain frustratingly present and challenging. Privacy, interoperability, liability issues and physician reimbursement are all main stays of resistance to the move towards wide scale adoption of the EMR. As expected there are some frightening stories to hammer home the point from an emergency room physician who estimated he treated 80,000 patients "with my own hands

...the thing that stuck out as he looked back on his career was how many times he was put in a position of "guessing over and over," "flying solo," in an information vacuum. In situations where people "die right in front of you," he said he often felt he was "one data element away" from stopping a patient from dying.

Needless to say there continues to be the naysayers who are convinced that physicians " know what they are doing; why do you want to tell them what to do" but in all this seem oblivious to the tsunami of knowledge rushing down the luge of clinical practice that is impossible to keep up with.

I agree with John Halamka

that the lives of primary care physicians -- snowed under by paperwork that does not require an M.D. but is required nonetheless, frustrated by prescribing a medication only to find out it's denied by the insurance company and terrified of making a mistake -- is sheer misery. He predicted they will welcome the help, and patients will be better off for it. As the system stands now, "all the medical students are becoming dermatologists," he said.

And it's easy to see why with the information overload with "medical literature published every month that is is more than a doctor could read in a year". Not to mention declining reimbursements and shattered dreams that litter the halls of our hallowed medical facilities. We need EMR's and EMRs need data to provide the decision support that an automated and optimized medical technology infrastructure can provide physicians in their daily practices. But all of this should not turn clinicians into data entry or data capture clerks - they are not good at this task and technology is available to facilitate this issue and provide clinicians with the tools to ease the burden and provide them with the necessary clinical decision support they want and need.

A Facebook Medical Record

What are we trying achieve with medical records....? Asides from the obligatory proof that the care was delivered (billing) and determining how much should be paid for the delivery of that care medical records are about sharing information between care givers. It has always been that way. Years back the number of care givers was lower and specialization less so the number of people needing accessing to the this information was lower. Now with the tsunami of medical information it is impossible for single care givers to deliver all the possible ranges of care and it takes a village team to deliver care.

And the latest explosion on online activity - one who's traffic can exceed that of Google and you tube is Facebook, which according to their own description

...is a social utility that connects people with friends and others who work, study and live around them. People use Facebook to keep up with friends, upload an unlimited number of photos, share links and videos, and learn more about the people they meet.

Now take this concept and adjust the wording.....

FaceBookHealthRecord is a social utility that connects patients with their care givers and others who provide diagnostic services, imaging, laboratory tests, results and pay for that care. Patients and clinical care givers use FaceBookHealthRecord to keep up with the status of their healthcare, their wellness and long term disease outlook as well as communicate quickly and effectively with specialists. All images, diagnostic study videos and diagnostic testing information can be uploaded and shared withe the clinical team allowing everyone to learn more about he care of that patient.

The interaction concept has been tested and reported on - Bob Wachter wrote an article just recently on this very concept "Creating a Facebook-like medical record" where he slams home the point on interoperability

In fact, today’s medical record virtually guarantees the silo-ization of care. Few physicians ever read nurses’ notes, even though all of us depend on the nurses to be our eyes and ears. And the situation iteratively worsens every day. Why would a nurse, realizing that no doctor ever reads her notes, even try to write them to be useful to physicians? And visa versa, obviously. Over the years, this divergence has been codified into ritual, calcified by templates, and hard wired through regulations whose original rationale no one can remember

Interestingly he points out that the spooks have gotten in on the concept with FaceBook-007 aka A-Space (I am guessing short for Analytical Space...?). Launch is set for Sep 22, 2008. UCSF back in 2003 launched a concept very much in line with the sharing of information amongst all the related parties (notably not the patient in this case) called Synopsis

As with all folklore associated with good concepts it was an rapid victim of its own success receiving requests for access, being copied and installed at other locations by users and even covered on a Web based M&M rounding on the Agency for Healthcare Research and Quality (AHRQ) site

There is work on these concepts underway and even some launches - if you live in New York you can sign up with HelloHealth from MyCA Health group who liked the approach taken by Jay Parkinson (the Hipster-MD from New York- pdf) who launched his own home made system with a similar ideal of sharing information digitally and providing easy, affordable access to patients some months ago. The NHS in the UK is getting in on the act with the "Individual Health Record" and covered in a recent article "Personal Healthcare Management" (subscription required) in my regular column in the British Journal of Healthcare Management.

There is even a Facebook application - MedCommons available today for a subscription plus monthly storage charges. Unfortunately much of what will be transferred in is likely to be scanned images and print outs. The introductory video even shows your physician office receiving access to your medical data and printing it out.....sigh! This will change but for now we are stuck with the legacy information

No doubt there will be detractors and there are bound to be issues and problems but overall you have to like the idea of sharing data on the quickly and effectively with the full clinical team. And there lies a key point.... the information must be be clinical data and should be tagged to a controlled medical vocabulary to make this information valuable for automatic machine processing. But lets not burden the clinicians with entering data in online forms but provide tools that capitalize on clinical documentation and the natural expressivity of language while still creating the structured data that can be used by these connected applications.

What to Believe in Todays Information Tsunami

It is a confusing world we live in and making choices is becoming increasingly difficult
Today is a great example of the conflicting nature of information available for our own personal healthcare

Half of overweight adults may be heart-healthy, which includes statements such as

The first national estimate of its kind bolsters the argument that you can be hefty but still healthy, or at least healthier than has been believed.

and Obese people not always unhealthy

... 1/4 of people who were a healthy weight actually had health problems such as high blood pressure, low levels of good cholesterol and high levels of bad fats in the blood.

....over half of overweight adults and almost a third of obese adults did not have these problems.

Versus the long standing advice you can see here, and here, and here
and published articles such as this one published yesterday: Measures of Obesity and Cardiovascular Risk Among Men and Women from the American College of Cardiology that concludes:

This study adds to extensive prior findings, which associate adiposity, in particular abdominal adiposity, with increased risk for CVD

On the same day as news feeds such as CBS and the Times included Why elderly joggers just keep on running.The conclusions included:

California Couch potatoes might not like to hear it, but running regularly has long-term health benefits that last well into old age, according to a study.

Elderly joggers remained fit and active for longer than non-runners and were half as likely to die early, scientists at the University of California at Stanford found. They were also less likely to succumb to age-related illnesses, including heart disease, cancer and neurological disorders.

It's a complex world and making sense of all of this "information" is a significant challenge for everyone, users, patients and professionals alike. The key to helping sort through this data is providing ready access to latest validated research and pushing this data into the consciousness of the users and clinical professionals. Pushing means we need to comprehend the clinical findings, signs, symptoms and tie them back to our clinical databases. This will link the knowledge and information in these clinical databases and push out supporting information to the decision makers which includes the clinical professionals as well as patients themselves. Capturing clinical information as data is one of the first steps in this process - entering it as items on digital forms is one way but that process can be laborious and time consuming so providing alternatives that match current processes is helpful. Dictation of clinical documentation is a prime example that needs to update the way it captures this data and how we achieve this should reflect this growing need for data not text.

As we think about the future of documentation, the data content locked in our traditional documents must be set free to help our healthcare providers and patients start to make sense of the conflicting information feeding in to our clinical decision making

Oh..... and for what it's worth; exercise good and obesity bad.