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The Myth of Prevention and EHR’s?

I was just referred this article which I found to be thoughtfully crafted. Abraham Verghese is a Professor and Senior Associate Chair for the Theory and Practice of Medicine at Stanford University. I found the article interesting, by somewhat anachronistic in terms of his perception of prevention and electronic medical records.

First, he raises an important point about the many overstatements as they relate to prevention. When we talk about how effective screening programs could be in identifying people for early interventions we have to realize what we are saying and what tools we are using for identification. Some tools can be too blunt, and not find the people we are looking for (false negatives), while other tools can be too sensitive and capture too many who actually may not have the disease (false positives). This is brought home in the example Dr. Verghese uses around the pitfalls of new diagnostic imaging equipment (and the situation is much worse with genetic testing at this point in time!).

With these newer, more sensitive imaging studies you can pick up calcium deposits in a health individual can lead you down a pretty wild (and expensive) goose chase for someone who is completely asymptomatic. He also demonstrates that the “value” of some prevention recommendations as somewhat questionable  – meaning – that while taking cholesterol lowering drugs has clearly shown to be efficacy reducing cholesterol levels and cardiac risk, is it really worth $150K/additional life year extended?

Well, that depends on if it is your life I assume. My point being, that you need additional information to be able to make these difficult, complex decisions. You need to not only know the relative efficacy of the regimen, but also the cost of the regimen to truly get at the “value” of the intervention. In addition, patients have modifiers to which they will place on the intervention in terms of cost in time, pain, and other inconveniences that are unique to their own values. This is where shared medical decision making can have such an impact – lay out the good, the bad, and the ugly and allow the patient to make a decision based on all the available evidence according to their own value system.

I don’t think these types of decisions can be made with the type of information we have today within the current clinical infrastructure. First, the physician gets paid to order the test and not talk to you about whether or not pros and cons of whether you should get it. Furthermore, the doctor has very little to no data upon which to inform that conversations anyway. In the relatively rare areas in which we have evidence, we might not have other components required for decision making in terms of cost and experience of patients undergoing regimen. In the case of prevention items mentioned above, we might choose not to go on statins at $150K per year but instead invest $10,000 in a personal trainer who is going to get rid of the root problem anyway. Without the underlying information, this would never even surface as part of the decision making process. We absolutely must be gathering, comparing, and sharing result outcomes in order to increase our capacity as healers who use the right treatments for the right patients at the right time and in the right way.

Which leads me to my final point – you absolutely need EMR’s to function as an 21st century physician knowledge worker. We are purveyors, translators, and mediators of medical information for our patients. They can get most of it on their own now, but we can still add significant value through our interpretation, personal experience, and ability to process the myriad data points with our clinical acumen (the sum total of our diagnostic prowess which comes from experience, practice, expertise, and intuition).

The EMR can be a very effective tool to help us gather, process, and present this information in a way that is meaningful and useful to our patients (actually most EHR’s don’t do this natively today, but with little effort a physician can lift the required information and present it in a format that is highly useful [alling all designers – get into health care!]). Furthermore, I truly dislike the characterization that the EHR makes the relationship cold and sterile.  I believe the current  generation of physicians, who have all grown up with the internet, see the EHR as an indispensible tool that helps them be more effective, efficient, and caring for their patients.

My sense is that I am more optimistic that we will get there with prevention, and that EHR’s will play a vital role to give us the clinical feedback to know whether our treatments (or prevention) efforts are having the impact that we hoped. Furthermore, I am hopeful, that efforts like the X PRIZE and others will help drive us to associate those outcomes with the total costs required to help us acheive the results so we can begin to understand the true value of the intervention. It is in this setting of data liquidity and information transparency, that they myth dissipates into a new reality of next
generation medicine.

Scott Shreeve is a physician and entrepreneur based in Laguna Beach, California. After a long career in medicine, Scott founded the open source electronic medical record company MedSphere. He currently serves as entrepreneur in residence at Lemhi Ventures.  Scott is a frequent contributor to both THCB and the Health 2.0 Blog. He blogs regularly at CrossOver Health, where this post first appeared.

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11 replies »

  1. Thank you for your data. We are all unhappy with the results in hand, we all need to join in to our ideas and solve our problems with all we need, health is important as families should be with them, not without or even pay needed.

  2. Hi,
    I appreciate the frustration that others feel with the slow transition from paper to pixels in medicine, but the issues are WAY more complicated and nuanced than it seems.This is not a conspiracy, nor is it a plot for doctors to secure their position as high earners. Most docs I know and I am married to one, would love for the data to be easier to centralize and maintain. But look at how data fidelity errors could cost people their lives- small errors propagating poor decisions in a diagnostic tree- and look at how fast incorrect data
    can spread- like the rumors of celebrity death on Twitter- and ask yourself if you want fast, or you want accurate when it comes to your health care.
    We want doctors to still be magic, yet be as concerned with customer care and treat us like family, yet we want them to do it as cheaply as possible.
    Data fidelity is as much an issue as is accuracy. Without more investment in standardization of data collection, sharing data between providers and institutions causes more problems than it solves.
    What is on most peoples mind is the Start-up cost?
    For more info please log on to http://www.radiologytranscriptionservice.com
    OR
    e-mal steve@radiologytranscriptionservice.com
    Call Toll Free; 1 877 323 4707

  3. Bill Crounse: I guess we can all agree we never would be in the mess we are today if we had never developed clean water supplies or penicillin. Talk about unintended consequences.

  4. You are confusing the cost per year of extended life and the cost of the statin. Both the statin and the health club personal trainer cost about the same. Most likely, you won’t individually benefit from either. Most club members don’t train for long. Many statin takers may either not have a cardiac event even without the statin and some will have one despite the treatment. Some will have a side effect. There is a statin benefit, but you have to treat a lot of people for a long time to save a life, Unbiased data is hard to come by. Gym memberships are a common adverse selection technique, appealing as they do to the already fit.

  5. The cost for year of healthy life gained with statins depends on a number of factors. Since people will take statins for a number of years and some will have only a small reduction in mortality (possibly only months), the cost per year of healthy life gained will vary.
    I looking at the research (Google is your friend), I found ranges from $1,000 to $350,000 per hear of healthy life. This one review of the JUPITER study seems representative and showed a $15,000 to $350,000 range. If you treat more ‘healthy’ people, you have a smaller return.
    http://www.expert-reviews.com/doi/pdf/10.1586/erp.09.5?cookieSet=1

  6. Thanks, Scott. Clearly you get it. It’s too bad that a lot of this is over the heads of folks in D.C. trying to “reform” healthcare. They don’t always appreciate that healthcare is like a balloon. You squeeze in one place and it just pops out in another. If we stomp out heart disease and cancer, we better start building and staffing more dementia centers. And by the way, long-term care for dementia patients is labor intensive and really, really expensive.
    Yes, docs and other clinicians are information workers and they deserve the best IW tools on the planet. I agree that we need to do much better on user interface and tools that facilitate rather than impede clinical workflow. This is an area where we (Microsoft) have been making some big investments; see http://www.mscui.net. Check out the “patient journey demonstrator” using Silverlight.
    Thanks again for sharing your insights.
    Bill Crounse, MD, Senior Director, Worldwide Helath, Microsoft

  7. Scott,
    Where are you getting your statin cost of $150K/additional life year extended figure? A 10mg daily dosage of Lipitor can be purchased for roughly $70/month or $800/year. This is far short of $12,500/month or $150,000/year.
    Doug Arnold

  8. I read the article a week or so ago. Good article. More interesting however is what is the status of Medsphere and do you and your brother no longer have any involvement in it?
    Likely you have written about that, but where can I find a reference to that?

  9. Great take on a very relevant issue. I think you are missing some basic steps to make this happen. First most people do not have enough data in the system to create a registry to find what I would like to call the ticking time bombs. To do this we will need to have a basic health screening tool set to gather baseline data on a population and this tool must develop some easy to understand health status score or grade. Second is the current system does not have the correct incentives in place for the provider or the patient to follow basic standards of care. I think we need to make it clear that we are going to pay providers on a health outcomes basis not a health process basis and we are going to use incentives to drive patient behavior change.
    I think we currently have all the tools and the resources to make this happen. What we are missing is the ability to hook them all up on scalable platform. Currently EHR’s are mostly just glorified data storage tools. To move to the next level we need to make EHR’s plug and play (ala Vince Kuraitis).
    My last point is that I do not think we can solve this on a national level. We need to focus on where healthcare occurs – in the community where that patient lives and the provider currently practices.

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