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Posts Tagged ‘diabetes’

There have been a number of research studies published that question the value of Electronic Health Records (EHRs), particularly as it pertains to improving quality of care and ultimately outcomes. Chilmark has always viewed these reports with a certain amount of skepticism. Simple logic leads us to conclude that a properly installed (including attention to workflow and thorough training) of an enterprise software system such as an EHR will lead to a certain level of standardization in overall process flow, contribute to efficiencies and quality in care delivery and ultimately lead to better outcomes. But to date, there has been a dearth of evidence to support this logic, that is until this week.

Yesterday evening the New England Journal of Medicine published the research paper: Electronic Health Records and Quality of Diabetes Care, which provides clear evidence, albeit a little fuzzy around the edges, that physician use of an EHR significantly improves quality metrics over physicians who rely on paper-based medical record keeping processes.

The research effort took place in Cleveland as part of Better Health Greater Cleveland from July 2009 till June 2010 and included 46 practices representing some 569 providers and over 27K adults with diabetes who visited their physician at least twice during the study period. Several common quality and outcome measures were used to assess and compare EHR-based care to paper-based. On composite standards of quality, EHR-based practices performed a whooping 35% better than their paper-based counterparts. On outcome measures, which are arguably more difficult for physicians as patients’ actions or lack thereof are more integral to final outcomes, EHR-based practices still outperformed their paper-based peers by some 15%. The Table below gives a more detailed breakout.

While the authors claim that insurance coverage has little bearing on the final analysis (i.e., Medicare, commercial and Medicaid patient metrics are similar) there is a surprisingly high percentage of patients in paper-based practices who do not have any insurance which makes one wonder: Will future Health Insurance Exchanges (HIX) and the individual mandate, should it survive the Supreme Court, have some bearing on what physician a patient may chose in the future? Will patients migrate to those doctors that use more advanced technologies (EHRs)? Also, there was an abnormally high percentage of patients in paper-based practices that were “Nonwhite” which raises another question: Could those practices that still rely on paper-based processes be in more disadvantaged neighborhoods? If that is indeed the case, will HITECH and its incentives trickle down to this strata of the healthcare sector? All in all though, these are relatively minor points in relation to the broader implications of this paper.

Implications:
This research paper could become a seminal piece in support of the current administration’s efforts to reform the healthcare sector as it not only supports efforts to digitize the healthcare sector via EHR adoption, but may also provide an added incentive that goes beyond HITECH Act incentive payments.

Throughout the healthcare sector reimbursement models are changing from fee for service to value-based contracts. Such value-based contracts, be they ACOs, PCMHs, P4P, or whatever other acronym you want to throw at it, are accelerating coming not only from the government but also commercial payers. A key component of these value-based contracts is achieving certain quality metrics and moving from episodic care to continuous care models. This research paper is one of the first and most comprehensive that has come across our desks here at Chilmark Research that clearly shows the use of an EHR has a significant impact on key quality measures, in this case diabetes care. While virtually all hospitals are on the HITECH bandwagon, it is less clear just how many private physician practices are jumping in and adopting EHRs for their practices. For many such practices, the HITECH incentive payments may not be enough of a reward for the numerous Meaningful Use hurdles that a physician needs to jump through. But if you hit these physicians directly in their wallet with value-based contracts and they see that EHRs provided demonstrably better quality care metrics, then we may see broader EHR adoption in the ambulatory sector. Bit of a crystal ball forecast, but the logic is there.

Ultimately, what we are seeing happen in the healthcare sector is not dissimilar to what we saw occur in the manufacturing sector. In manufacturing the lag between adoption of enterprise software systems and subsequent increases in productivity has a special term: the “Productivity Paradox,” wherein it was some ten years after wide spread adoption and deployment of these enterprise systems that improvements in productivity metrics could be measured.

Might the healthcare sector have its own paradox? We think so and from this point forward will refer to it as the Quality Paradox.

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There remains an unhealthy level of skepticism in the market as to whether or not consumers will use a personal health record (PHR). While a certain level of skepticism is healthy in any market, the level to which it is laid towards PHRs is unwarranted and likely more a function of ignorance then malicious intent. Following is a brief PHR case study that provides validity to the mantra that a patient who is provided access to their personal health information (PHI) via a PHR can become a more engaged patient in self-managing their health. What is particularly striking about this story is that it is does not take place in middle-class America, where many have targeted their PHR initiatives, but rather among the urban poor.

Yesterday, I met with Dr. Nunlee-Bland, Director of  Howard University Hospital’s (HUH) Diabetes Treatment Center, who graciously provided the context and content for this remarkable story.

Empowering the Urban Poor to Self-Manage Their Diabetes:
In 2008, HUH received a grant from the Dept of Health, DC to launch a diabetes treatment program primarily targeting urban poor. As part of this grant, HUH launched a PHR initiative creating a patient portal using NoMoreClipboard (NMC), linking NMC to their clinical diabetes EHR, CliniPro from NuMedics. The PHR provides patients with access to their problem list, vitals (height, weight, blood pressure, BMI), medication lists, basic lab results, A1C results (can be charted for track and trend) and basic demographic information. While Dr. Nunlee-Bland stated that HUH has no reason not to provide patients with full access to all PHI, they have purposely kept the PHR simple and focused on the treatment of diabetes.

The PHR is available to all 1,000 patients currently enrolled in HUH’s Diabetes Treatment Center. Of that population, roughly one third are elderly, receiving Medicare, another third have commercial insurance from their employer and the final third are on Medicaid. Patients are introduced to the PHR during an appointment with a clinician encouraging patients to use the PHR to assist them in self–managing their diabetes. Today, 26% of patients are using the PHR and an additional 1% of the total diabetes patient pool are enrolling in the PHR on a monthly basis. In a market where PHR adoption sits at ~7%, 26% adoption is remarkable, especially when one considers that this is the urban poor we are talking about.

Assumption: Urban poor do not have computers so an online PHR is of no use.
In reality, HUH’s own survey has found that 70% of all patients have a computer. The number one reason patients cite for not signing up for the PHR is lack of internet access. Computer is not the issue, access is. (As a footnote, privacy was one of the least concerns with only 5% stating it was an issue.)

Digging deeper into those adoption numbers an even more revealing and stunning finding comes forth. While diabetes patients are evenly split across Medicare, Medicaid and commercial insurance, adoption and use of the PHR is not. The highest adoption and use of the PHR is among Medicaid patients, who make up a whopping 87% of all diabetic patients at HUH using the PHR. Why the strong adoption among this sub-group? Fragmented care. Dr. Nunlee-Bland explained that Medicaid patients must move from one provider or clinic to another to receive treatment – there is no consistency for this group as to where they receive their care and the PHR provides this group a “medical home” for their PHI which they value.

Assumption: The poorest are least likely to use the PHR.
Medicaid patients are at the forefront of dealing with a fragmented healthcare system, they are the most vulnerable but also the most willing to take action to gain some control over their treatment and empower themselves with access to their PHI. Young Medicaid patients are even going a step further, through personalization, e.g. uploading their picture to the PHR.

While the program is less than two years old, HUH is already seeing results. Prior to launching this project, the average A1C levels for patients was 8.8. Today, that number is at 7.6 (~14% drop) and is continuing to trend downward. Dr Nunlee-Bland attributes this to the patients having access tot heir PHI, particularly the ability to see trending data in the PHR. This information provides the patient the ability to visualize their progress. HUH has also seen a decrease in ER visits by patients using the PHR.

Myth: PHRs offer little clinical value.
Most patient portals/PHRs that healthcare organizations have put in place are run by the marketing department to promote patient retention. The idea that a patient portal could be far more than that, e.g. a clinically useful tool to improve patient outcomes, is something that exceedingly few healthcare organizations have embraced.

In May 2010, HUH began offering some mHealth capabilities to the PHR. Available for those who use a smartphone, the mHealth App provides alerts to upload glucose readings directly from their smartphone as well as provide periodic reminders to say have their eyes checked, get their A1C labs done, etc. Currently, there are 34 patients using the mHealth App, all of them young, Medicaid patients. Though launched just a few months ago, early results are promising with those using the mHealth App even more engaged (more self-reported glucose readings) in managing their diabetes (A1C values trending downward faster) than those using just the Web-based PHR.

Lessons Learned:
Dr. Nunlee-Bland stated that there are three key requirements to make such a program actually work in the field. They are:

1) Leadership: The provider/sponsor has to truly believe in the program and through that belief, bring others on-board. Without strong leadership coming from the very top of the organization, such a program will falter. Even today, one of the biggest challenges HUH faces is getting primary care physicians (PCP) outside of HUH to believe in and use the PHR as a significant number of patients who have not signed up for the PHR state that they see no value in it if their PCP sees no value.

A primary objection that PCPs have cited is that the PHR does not readily flag what is patient-entered data versus that from HUH. This is a problem that HUH and NMC are working on together to address.

2) Focus on ease of use: The PHR is pre-populated with data from the EHR and data from office visits, including updated notes, labs, etc. are automatically, nearly simultaneously loaded into PHR as well, minimizing any manual entry by the patient. While HUH encourages patients to enter their glucose readings directly into their PHR between visits, the data entry process is manual and adoption of this process is almost non-existant. However, the recent introduction of the mHealth App has shown a marked increase in patient entry of glucose readings as it is a far simpler process and is readily at hand in the form of their smartphone, which is always with them.

3) Be patient, this take s time: Installing and going live with the PHR is just the beginning. Significant training, which always takes time, of both patients and clinicians is required to drive adoption and use.

Closing:
With the coming changes in healthcare payment models looming just around the corner, changes that will require a higher level of risk-sharing by healthcare institutions who will be paid based on how well they manage patient populations, healthcare executives would be wise to go back and rethink their patient engagement strategies. In the not so distant future, successful healthcare institutions will not look at their patient portal strategies as simply another checkbox they need to address to meet meaningful use requirements, nor will they see it as just a marketing program, rather they will use such capabilities to engage patients as an active and engaged member of the care team that, as in the case of HUH, will lead to higher patient compliance and ultimately lower patient healthcare costs. And do keep in mind that any assumptions one may have as to who will be most engaged in using such tools should be left at the door.

Thank you Dr. Nunlee-Bland for opening this analyst’s eyes and erasing a few assumptions of my own. Also, note that Dr. Numlee-Bland will be on one of the late morning panel at the forthcoming HHS-FTC sponsored PHR Roundtable event on December 3rd.

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Stumbled across this research paper today on Web2.0 design patterns for chronic care of pediatric patients (prototype, diabetes type 1). Authors are from the Swedish University, Linkoping University.

This technical paper addresses patterns in Web design and use of Web 2.0 tools. While most of the paper coveres the fundamentals of Web-based design and the unique constraints that need to be applied to healthcare, I found the references, appendix and figure on last page to be most useful.

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Highlights of this morning’s keynote by Craig Mundie, Chief Strategy Officer at Microsoft.

Computers will be more pervasive and work in the context of what an individual is doing – think GPS and restaurant search ala iPhone. More broadly, and in a healthcare context, think real-time diabetes monitoring, coupled to intelligent alerts. Last week’s Project HealthDesign had a good example of a diabetes monitoring system that is well worth watching.

Spatial Computing: Computing outside the normal PC construct and compute within the Cloud. As cost of sensors continue to fall they will increasingly be a part of the fabric of future computing. This will lead to computing becoming model based, vs. the discreet applications we have today. More humanistic computing will be the result including the moving to 3D display and highly adaptive systems.

Mundie gave a brief example during this part of his talk of a controlling a robot representation in a 3D visual environment with objects, which were obeying first principle physical laws falling over as the robot bumped into them. Thought to myself, doesn’t look much different than a gaming environment. Then it struck me, damn, this looks familiar! Willing to place a very heavy bet that what he was actually demonstrating is a gaming computing environment from what was a small and very innovative French software company, Virtools. Virtools was acquired by my former employer Dassault Systemes a few years back and no, this is not something new that has yet to reach the market, which to me Mundie inferred, but a technology that has been in the market for several years now – it just doesn’t have that much visibility outside game development community.

Demos:

  • Photosynth: A new technology developed at MS that takes numerous 2D photos and creates a composite to create a 3D composite model of the real world.
  • Robotic Receptionist: Plan to beta test at MS campus in next couple of months. Using an 8-core high performance computer, uses roughly 40% of computing power continuously – what a CPU hog! Most dual-core processors on one’s PC use only a few percent in any given computing task. Gave a quick demo, very bizarre is the best way to describe it. Still on the crude side, but not unlike something you would read in a Gibson SciFi novel.

Concurrency and Complexity: Applications that are loosely coupled, asynchronous, concurrent, composable, decentralized and resilient. This is what the Internet is bringing to the future of application development but the tools today to create such are really not there yet. Creates new challenges for computer programmers. Certainly creates challenges for MS who is so tied to the PC construct.

Making things simple for the end user is an incredibly difficult task for programmers. Developing applications that understand the context by which the user interacting with the computer is something that MS is still trying to figure out. Mundie readily admits that today, programs still make the user conform to the computer rather than the computer conform to the user. This is the next big issue to tackle in the comuter industry.

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When those in the industry talk of PHRs and adoption by consumers, virtually all of the focus is on two categories of users who dominate PHR use today, consumers with chronic care needs and a family’s chief medical officer, the woman of the house. Both groups of users are by and large from the middle class.

While all of the focus is there, I am beginning to see some PHR roll-outs for a new class of PHR consumers that I’ll refer to as the “disadvantaged”. When speaking of the disadvantaged I am referring to those that are low wage earners, have irregular access to healthcare, relying predominantly on clinics and emergency rooms for care, and often do not have insurance. These users may also have limited access to computers and the Internet, but most will likely have a cell phone.

In early August, I had a post on a sponsored PHR program in California for migrant workers based on the successful MiVIA platform from FollowMe. (Nice to see a government agency put money on the table for a viable pilot program – why the feds can’t do this is a mystery to me. Then again, maybe all those tax dollars are going to support another failing RHIO as part of an ill-conceived NHIN.)

Late last week I was speaking to another PHR vendor who has more on their plate then they ever imagined. This vendor was quite proud of a recent win at a well-known University. The University intends to use the PHR as part of a broader diabetes education and compliance program for inner city residents. The goal is to tie local outreach and education efforts with tools (a PHR account) that the consumer can use to help manage their diabetes.

Today, there is extremely little in the market to educate consumers on the value of a PHR. Most simply stumble upon a PHR or are referred to one by a friend, family member, associate or maybe their physician. Such outreach efforts at the lower economic strata of our economy may provide extremely valuable feedback and lessons on what is needed for a broader educational campaign to motivate consumers to take a proactive roll in managing their health.

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There are any number of statistics that one can point to telling us we in serious trouble. From the epidemic that is obesity to the persistent climb in diabetes cases and let us not forget Alzheimer’s, a disease that cripples many an elderly adult and is projected to rise to some 16 million cases in the US as baby boomers age and fall victim.

The future will be extremely challenging for both those suffering with these diseases as well as the caregivers who look after them. Numerous tools and platforms are being developed to help assist one in managing their or a loved one’s care, but they tend to be islands unto themselves. Personal Health Systems (PHS), such as Dossia, Google Health, HealthVault and maybe even RevolutionHealth and WebMD have the potential to provide an integrated service, but we’re still several years away from that becoming a reality.

While I do research and write on the the topic of consumer-centric healthcare technology and the desperate need to change perspectives from one that is patient-centric to one that is consumer-centric, there are others who search for the keys to health, such as genetic markers for Alzheimer’s to help us avoid falling victim to such diseases in the first place.

In the brief clip from a local cable network, Alzheimer’s research at Mass General Hospital is highlighted. Proud to point out that my son, who recently started working in this lab, makes a cameo appearance (he’s the one behind the scope).

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This week, the California Healthcare Foundation (CHCF) announced that they were expanding a a pilot diabetes monitoring program, nearly quadrupling the number of clinics from the initial 12 to 42.

The purpose of the program was to perform retinal screening fro diabetic retinopathy, which often results in blindness.  In the pilot, which took place in the Central Valley off California, a rural agricultural area with  a large migrant population, the 12 clinics were set up with a retina scanning system that allowed doctors in remote clinics to take high-resolution retinal digital pictures, send them over the Web to California Berkeley School of Optometry for expert consultation and recommended follow-up procedures.

Over the two years of the pilot, a total of over 24,000 patients were screened, of which nearly 50% had signs off retinopathy, with 15% requiring direct referrals.

Nice example of what is possible, question is : Must foundations such as CHCF fund such programs?  Where are the payers who would apparently have the most to gain from sponsorship of studies such as this?

While I applaud CHCF for sponsoring such new, innovative approaches to delivering care, I sure would like to see much, much, more from the payers.

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