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Google Health: What Did We Learn About PHRs?

Dec 1, 2018

By SHAHID N. SHAH

As I mentioned by way of the Wall Street Journal back at the end of March, Google Health was supposed to get less support under the new CEO. We learned today that “less support” meant that it would be retired on January 1, 2012 and eventually shut down on January 1, 2013. Basically this means that the grand experiment didn’t work out, but it was valiant and worthy try.

The folks at Google raised the bar for PHRs and I for one was a fan; however, if Google couldn’t make it work, does it mean that Personal Health Records (PHRs) in general aren’t worthwhile or won’t be successful? I don’t think so, but what we learned from the Google experiment is that there’s little or no demand from the general consumer to store their personal medical records — at least in numbers that would matter. Here’s what Google said in their retirement letter:

There has been adoption among certain groups of users like tech-savvy patients and their caregivers, and more recently fitness and wellness enthusiasts. But we haven’t found a way to translate that limited usage into widespread adoption in the daily health routines of millions of people.

PHRs managed and maintained by patients themselves has been sort of a holy grail for years — but no one has been able to figure out how to make enough money from them or keep the data accurate enough to make PHRs useful enough to clinicians. And, it’s not for a lack of trying; in fact, Microsoft’s got a nice offering (HealthVault) that’s still in good shape so far. But, it’s not clear how long even they can last without a sustainable business model. It’s not like Google didn’t have the money to continue the experiment — they just realized that there were not users in quantities high enough for them to be able to monetize it sometime in the future.

Health Reform: Evidence-Based Medicine and the Real World

Dec 1, 2018

By RICHARD REECE, MD

The July 7 edition of the New England Journal of Medicine just arrived. It contains two back-to-back articles that illustrate the problems of transforming medicine into an evidence-based format.

• The first is “Lessons from the Trenches – A High Functioning Primary Clinic.” Its author, Thomas Bodenheimer, MD, a well-known University of California academic, describes the workings and make-up of Clinica Family Health Services, a Denver-based primary care community health clinic. The clinic serves 40,000 patients at 4 sites. Fifty percent of these patients are uninsured; 40% are on Medicaid. Clinica aspires to be one of the first Accountable Care Organizations. Each of its locations includes three primary care practitioners, three medical assistants, a RN, a case manager, a behavioral health professional, and medical-records and front-desk staff. The clinic “has moved boldly from a doctor-based model to a team-based model.” Patients are never turned away, and most are seen on the day they call. The 4 clinics have a linking EMR, and they concentrate on assembling data that show progress. These data includes time it takes to see a primary care doctor or to meet with “the team,” entry to care during 1st trimester, number of low birth rate infants and % of Cesareans, Pap test within last 3 years, number of patients with diabetes and their glycated hemoglobin levels, and number of patients with hypertension. The goal is to improve all these measures. The basic idea is to serve patients while retaining loyal clinicians. The next step will be to reduce ER visits and hospital admissions. This step “awaits a new funding stream, which requires participation in which Clinica will share savings from reduced downstream costs.” To which I say, “ Good luck.” Many observers, including myself, say Accountable Care Organizations are DOA.

Why Do Doctors Offer Credit Cards?

Dec 1, 2018

By DAVID E. WILLIAMS

Yesterday’s Wall Street Journal (When Your Doctor Sells Credit Cards) documented the growth in credit cards issued to finance elective procedures such as LASIK, plastic surgery and dental implants. The article covered the usual points but missed one important but little-known aspect of the industry.

Briefly, physicians offer the cards for procedures not covered by insurance. The cards have a zero percent interest rate and no fees, usually for the first 12 months. After that the interest rates spike and to make matters worse customers are also charged retroactive interest on their first year’s balance. Ouch! The article details the pitfalls you’d expect from cards like these, and of course there have been some abuses.

A card company spokesman quoted in the article says, “the vast majority of account holders pay off their balances before the promotion ends.” That statement doesn’t surprise me, because most people who have these elective procedures are relatively well off.

FDA Mobile Medical Applications NPRM

Dec 1, 2018

By JOHN HALAMKA, MD

Many have asked me for an analysis of the new FDA Mobile Medical Applications NPRM.

The FDA will not seek to regulate mobile medical apps that perform the functionality of an electronic health record system or personal health record system. However, the FDA defined a small subset of mobile medical apps that may impact the functionality of currently regulated medical devices that will require oversight. Here’s a thoughtful analysis by Bradley Merrill Thompson of Epstein Becker Green, which he has given me permission to post:

“Today, FDA published the long-anticipated draft guidance on the regulation of mobile apps—more specifically, what the agency calls “mobile medical apps”. This draft reflects significant efforts by FDA in a fairly short amount of time, and we applaud that work. Much of the framework of the FDA guidance is consistent with the work the mHealth Regulatory Coalition (MRC) published on its website earlier this year (www.mhealthregulatorycoalition.org). While FDA has done a good job getting the ball rolling, there are a number of areas that require further work. We all (including FDA) recognize that this draft guidance is certainly not the end of the story.

The regulatory oversight recommended in today’s draft guidance applies only to a small subset of mobile apps, which FDA defines as any software application that runs on an off-the-shelf, handheld computing platform as well as web-based software designed for mobile platforms. To be regulated, as a first step the app would have to first meet the definition of a medical device and then as a second step either (1) be used as an accessory to another regulated device or (2) “transform” the handheld platform into a device, such as by using the platform’s display screens or built-in sensors.

Rhetoric Ahead of Reality: Doctor Ratings Not Useful Yet

Dec 1, 2018

By JESSIE GRUMAN

“Most physicians are competent and able to take care of most of the problems patients present with. The standards for getting into medical school are high and for getting out are higher. I think this call for patients to become experts in picking their doctors is overstated.” – David Rovner, MD, Professor Emeritus, Michigan State University

Most? What does “most” mean? Can most doctors treat me for the flu? How about pancreatic cancer? Must I conduct the same type of research to choose a doctor to set my broken arm that I do to find one to treat my mom’s congestive heart failure? Is the same level and type of research necessary to find a good surgeon as for a primary care clinician?

There are no easy answers to these questions. The steady stream of media messages and articlesurging us to thoroughly check out any new physician we might consult stand in stark contrast to my colleague David’s opinion. The release of the latest “Top Doctors” from the US News and World Report’s“Best” series is surely a sign that, in a declining print media market, lists of superlatives still boost magazine sales. But reports like these do little to help us understand what is at stake in doing so or to figure out under what circumstances it is important. Rather, they assume that we are sufficiently anxious or cautious to dive into conducting research prior to making any and all doctor choices.

The Usefulness and Uselessness of Electronic Medical Records

Dec 1, 2018

By RICHARD REECE, MD

Nothing is so useless as a general maxim.

Lord MacCaulay (1800-1859), On Machiavelli (1827)

I dare say that I have worked off my fundamental formula on you that the chief end of man is to frame general propositions and that no general proposition is worth a damn.

O.W Holmes, Jr. (1809-1904), as quoted in The Practical Cogitator, 1962

The general maxim and general proposition behind the rationale of a national interoperative electronic medical record system in every physician’s office is that you can never get too much information and that government can use digital data to cut costs and improve care.

The Problem

Sounds good, doesn’t it? The problem is that so far, after nearly a decade of advancing this maxim and proposition, perhaps 80% of physicians in independent practice aren’t buying. And this, in face of the reality, that government has proposing spending $27 billion to get EHRs off the ground. And beginning this year, CMS will start offering as much as $44,000 per physician over a staggered five years if physicians make “meaningful” use of “certified” medical records. Many doctors regard such rhetoric as empty talk that will accompanied by unreasonable bureaucratic requirements, as surely as dawn following night.

Why no “buy-in” among doctors? Why have two national IT coordinators appointed by Obama, David Brailer,ND, in 2005 and David Blumenthal, MD, in 2011, resigned in frustration over the failure to persuade doctors that gathering electronic data and measuring care is a good thing? If universal EHRs are such a good thing, why have physicians and hospitals not raced to embrace EHRs?

As Steve Lohr of the New York Times, a leading thinker in health care innovation, says in yesterday’s Times (“Seeing Promise and Peril in Digital Records,”

“What is beyond doubt is that the promise of digital records will be unfulfilled if doctors refuse to adopt them, because they regard the technology as cumbersome, time consuming, and possibly dangerous.”

To date, most doctors, except for enthusiastic early adopters, IT nerds, and those in large organizations, have found EHRs “useless” in their daily work. EHRs cost excess money, show little return on investment, change the very nature of practice, slow productivity, tell no narrative tales, cause conflicts among staff and colleagues, require extensive record keeping, are subject to hacking, and, more often than not, are useless as a tool for communicating to colleagues, hospitals, and other doctors outside your practice.

When the government establishes “usability standards” that work, maybe doctors will come on board the electronic train. Until then, says Dr. Edward H. Shortliffe , a professor at the University of Texas Health Science Center in Houston, “Usability is going to be the single greatest impediment to physician acceptance. “

If EHRs are not made more useful and soon, universal digital records may turn out to be a giant boondoggle rather than a scientific bonanza.

Richard L. Reece, MD, is pathologist, editor, author, speaker, innovator, and believer in abilities of practicing doctors and their patients to control and improve their health destinies through innovation. He is author of eleven books. Dr. Reece posts frequently at his blog, Medinnovation.

Practical Collaborative Document Writing for Patient Communities

Dec 1, 2018

By FRED TROTTER

I have a lot of experience with collaborative document writing, and now, in my role with Cautious Patient Foundation, I have been providing technical help to several patient communities. I helped write the security standards for the NWHIN Direct project and I am currently working with the e-patient/QS community to create a document detailing Doctor friendly Quants and Quant friendly Doctors.

My advice is pretty simple:

Use a forum, either a facebook thread or a mailing list to determine who the primary authors should be, and what the general content of the document should be.Continue reading…

How Not to Create an HIE

Dec 1, 2018

By JOHN MOORE

Sometimes, the job of an analyst can be so frustrating.

A core part of the Chilmark Research charter is to educate healthcare stakeholders on critical trends in the marketplace that will lead to better, more successful adoption of IT and subsequently improve the health of the nation (if not the world). There are a couple of things we have learned along the way:

1) Little if anything gets adopted at scale in the healthcare sector (and for that matter virtually any other market) if it does not provide value to the end user that exceeds risk. That risk could be privacy, it could be a productivity hit, it may be liability; plenty of risk in healthcare, both perceived and real to trip up an IT initiative.

Is There an Independent Unbiased Expert in the House?

Dec 1, 2018

By SHANNON BROWNLEE

Last week, U.S. Food and Drug Administration Commissioner Margaret Hamburg told the advocacy group Public Citizen that the FDA may loosen conflict-of-interest rules for experts who serve on the agency’s advisory panels. These panels wield considerable power when it comes to FDA decisions about approving drugs and medical devices, and for pulling them off the market when evidence surfaces that they may cause patients harm.

Why loosen the rules? Commissioner Hamburg said the agency is having trouble finding experts to fill its advisory panel slots. In other words, anybody expert enough to be on an FDA panel undoubtedly has a conflict.

Or maybe the FDA just isn’t looking very hard. In 2008, Jeanne Lenzer — an independent journalist — and I created a list of more than 100 experts in fields ranging from epidemiology to neurology to emergency medicine, every one of them independent from industry conflicts of interest. We made the list available to our fellow journalists at the website, Healthnewsreview.org, a site that grades health stories. Dozens of journalists from top news outlets, including the New York Times,Bloomberg, and the Wall Street Journal, have requested the list, and used it to find sources for their stories — or at least we hope they have.

The Pace of Change

Dec 1, 2018

By JOHN HALAMKA, MD

My travels in Japan included lectures in Tokyo and Kyoto, sharing lessons learned from the US health information technology national efforts. I highlighted that the Office of the National Coordinator has to balance the desire for innovation with a pace of change that vendors and clinicians can tolerate.

This led me to think about the pace of change that CIOs are experiencing right now. The IT innovations of the past few years have been dizzying and the cycle between the peak of hype to the trough of obsolescence is now measured in months, not years.

Some examples of rise and fall

1. Blackberry – I was one of the earliest adopters of Blackberry technology, using a small pager-like device for short text messages. As each new model was announced, I welcomed the innovations – the evolution from thumbwheel to joystick to track pad, larger color screens, cameras, video features, and voice memo recording. However, in 2011, my mobile device needs have outpaced Blackberry’s engineering. I now need a full featured web browser, a book reader, the ability to zoom/drag via touch screen, and a robust App Store. Until 2010, Blackberry seemed to be unstoppable in the corporate messaging world. Now it is laying of 2500 people as the iPhone and Android devices rapidly replace Blackberries in consumer and business settings. They tried very hard to introduce new devices such as the Storm, the Playbook, and the Torch, but came up short as customer expectations exceed their pace of innovation.