These are two issues close to my heart. I have limited time to write on them now, maybe more next week. However if you’re interested go look at the ehealth intiative’s report on Electronic Prescribing (here’s the press release) and look at the AMA’s endorsement of an XML-based portable consumer health record.

Much to the chagrin of GE, Phillips, and Siemens (as well as patients who don’t want “garden hoses” shoved up their rear ends) a new study in JAMA shows that virtual colonoscopy doesn’t work as well as advertised.

Harris Interactive is out with its latest analysis of how many adults are online and who’s using the Internet for health information. After massive growth through the last decade, the number of adults online has stalled at around 69%, with 3/4 of those being online health seekers or “cyberchondriacs”–equating to around 51% overall. (The number of kids online is much greater–it tends to be the over-65s who are not online as frequently).

So the fast growth is over, and any future growth in online usage will probably be an aging out effect. Don’t forget that you just witnessed the fastest technology penetration in history, and all because the Pentagon wanted to send messages to its missile silos in the 1960s.

So this gives me a neat opportunity to remember what a great futurist I was (ha, ha). I’ve recently fessed up to several forecasts made in the Health and Health Care 2010 publication that, at the least, have to turn around to come close to matching current reality (particularly the bit about aggressive health care payers working to reduce costs over the Zeros….). Well back in 1996 in an IFTF report called Telehealth (we wish we’d called it eHealth) we had a nearly right explanation about the growth of online activity based on access to in-home appliances like PCs. Some of the technology is wrong (the Network PC never made it) but look the numbers, and you’ll see we were pretty close:

In its potential for mass applications, then, telehealth clearly represents a new market that is likely to have new and far-reaching impacts on patient care, provider organizations, and even consumer-focused pharmaceutical provision. How important it becomes and how quickly it becomes important depends on partly on its acceptance by physicians, patients and others involved in health care, but more importantly on the information infrastructure needed to run them. The key piece is consumer access. If the home computer becomes ubiquitous, then health care functions will be found to run on it, and telehealth will have a chance to take hold and take off. Currently 38% of American households have PCs, while 20% of U.S. adults have accessed the Internet or used online services. The important question for telehealth is, how likely is the penetration of PCs and other information of appliances to grow and by how much?

We conducted an internal workshop at IFTF in order to forecast the penetration of information appliances with the capabilities of 1996 home PCs with modems into U.S. households over the next ten years. This definition obviously includes both cable modem systems and the coming Network Computer (NC), as well as anything else Silicon Valley’s late night pizza eaters dream up in the next few years. Our consensus forecast was that by 2000, 50% to 55% of American households would have these appliances, and that by 2005, 65% to 70% would be equipped. Some of our outliers felt that this was much too low and that the appliances would be as common as color TV (i.e., 95% plus by 2005).

PC penetration is now around 61% and other forms of access to the Internet (including access to appliances like web TV, PDAs, and access at libraries and internet cafes) take us to 69% of adults online), our forecast of 65-70% by 2005 looks pretty good. With the preponderance of cable modems and other new technologies, it’s a fair bet that even the 95% level of adults online will be reachable by 2010, even if many people won’t want or need to use the technology. The rest of the growth in this market will be the aging out effect as todays kids become tommorow’s consumers until, like the phone and the TV, the Internet is part of the fabric of modern life for everyone.

Well we haven’t even got CPOE systems in more than a small percentage of hospitals (4%-15% depending on who you believe) and their validity as a major weapon against medical errors is already being questioned. A study in Annals of Internal Medicine looked at all medication orders in a large hospital in Chicago, over the course of one week in 2002 and tried to figure out what difference a CPOE system would have made had one been in place:

A total of 1111 prescribing errors were identified (62.4 errors per 1000 medication orders), most occurring on admission (64%). Of these, 30.8% were rated clinically significant and were most frequently related to anti-infective medication orders, incorrect dose, and medication knowledge deficiency. Of all verified prescribing errors, 64.4% were rated as likely to be prevented with CPOE (including 43% of the potentially harmful errors), 13.2% unlikely to be prevented with CPOE, and 22.4% possibly prevented with CPOE depending on specific CPOE system characteristics.

As the authors note somewhat dryly:

Prescribing errors are common in the hospital setting

The implications are laid out in this article in Health-IT World. Some half of the serious medication errors would not be caught by a standard CPOE system unless it had high level decision support software combined with it. In fact most CPOE systems do, even if the authors study poo-poos them.

The issue in practice is that if you set the warning levels too low, the clinicians can make errors. If you set them too high, the physicians just hit over-ride all the time, and make errors. Physicians and hospital IT folks I’ve talked to about CPOE have tended to start on the lowest levels of “warnings” and slowly ratchet up. But any computer use needs intelligence, and CPOE is no exception. That doesn’t mean that it shouldn’t be tried, and slowly it will become more common.

The latest battle in the cardiology war between drug-eluting stents seems to be going decisively to Boston Scientific. Their Taxus stent has barely been on the market for a few weeks and it’s already burning up the charts, already selling at an equivalent annual clip of over $1.2 billion. On the same day that their stock rallied on the good news its competitor J&J’s Cypher is having the dreaded production quality problems. That type of shooting yourself in the foot problem plagued Schering Plough in its recent downturn, and can take a while to sort out. By no means is a company of J&J’s size and reputation going to let this continue, and because of J&J’s overall size it won’t make too much of an impact on its stock price, but for the moment this round is clearly being won by the other side.

Milt Freudenheim has an article in the New York Times about the trouble that hospitals are having with computerized patient care. Well worth a read, even though the numbers about the current low use of CPOE and relatively low planned use of CPOE are well known in the academic press and I’ve blogged about them before.

The important part of the Times article is the fact that the public is getting a wider understanding of the slow progress health care is making. But it is making progress (finally) and according to the Gartner numbers in the NY Times article larger hospitals show remarkable progress in the number who are implementing CPOE and planning to implement it.

So the proof is in–informed medical decision making at the point of care for physicians works and they like it. A very large sample of physicians (over 5,000 surveyed, out of 55,000 clinicians who could access the system) were given a point of care information system. 63% of them knew about it and 75% of those, used it. 41% of those users reported that they directly improved patient care they delivered by using the system. (The results are in the abstract here).

The only reason that this isn’t sweeping American medicine as we speak is, of course, that the system is only available in Australia.

I’ve been working with a hospital system client who’s investigating how to create a number of initiatives to work with its various business partners. Chief among those business partners, of course, are doctors–who remain (believe it or not) the most important people in health care. One issue that hospitals are wrestling with now is how to extend their CPOE systems and wireless networks across their facilities, and of course integrate that technology into the business practices of their partner physicians. Of course, most of those physicians who work with the hospitals in this country do not employ them or own them. So that means that the hospitals, who are spending gazillions on information systems, now have to integrate those with physicians’ behavior–in other words with whatever the physicians are bringing in the backdoor.

On example of that behavior is blogging doctor Jacob at Family Medicine Notes. He’s got himself a new Treo 6000. Half the time he’s in the hospital, part of the time he’s in his office. He’s using IM in the hospital, and being paged there. And the Treo cannot yet get on the Wi-Fi, but that’s a matter of months at most. So now you’re a hospital CIO, you have the pressure to get your doctors to use that IT stuff, but then you have the backdoor men bringing their own stuff in. Plus not only do you have to make it all work on multiple platforms, you’ve got HIPAA saying that information must be protected even if its not on your system anymore. A confusing and difficult time for hospital CIOs, but when docs like Jacob are finally pushing the envelope on using technology to improve care and their own care process, an exciting one too, no?

Loads from the American College of Cardiology meeting including a detailed study on stent use in the carotid arteries from Guidant (here’s the more digestible press release) and also "proof" from J&J that drug eluting stents really, really prevent restenosis — honest!!

Meanwhile over at MedRants more on the latest with the statins. (Short version is that stronger is better so Lipitor beats Pravachol but may get bested by Crestor).

Funnily enough the meeting is in New Orleans, so from my recollection of the food down there, plenty of future work for these statins and the stent manufacturers is being created each dinner time!

UPDATE: Sydney Smith over at Medpundit has a very interesting take on the real world application of this study and isn’t so sanguine about it.

As this study from Solucient shows the take off in the use of drug-eluting stents has been very fast, even before Boston Scientific’s Taxus stent hits the market. USA today has a good general article about them too.

This puts hospitals in a real bind, as the cost of the new stents means that they’ll be losing money on their use, unless they can get an increase in DRG payments from CMS. So watch this space. But don’t forget that restenosis rates are real even for drug-eluting stents and that a recent Stanford study showed you were better off getting a by-pass over time.

UPDATE: The FDA today as expected approved the Taxus stent from Boston Scientific. The stock is up about 30% so far this year.