The Health Care Blog – Page 474 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Electronic Cigarettes: What’s in the Vapors?

Jun 30, 2014• 5

By Maciej Goniewicz

Users and non-users of electronic cigarettes (e-cigarettes) have many legitimate questions about these nicotine-delivery devices. E-cigarettes represent a nearly $2-billion-a-year industry, and one that’s growing exponentially. The number of young people trying e-cigarettes doubled from 2011 to 2012, according to the Centers for Disease Control. So it is natural that so many people are interested in the health consequences of using e-cigarettes.

Research from the Department of Health Behavior at Roswell Park Cancer Institute has documented the impact of first-, second- and third-hand exposure to e-cigarette vapors. Our most recent research, done in collaboration with scientists from the Medical University of Silesia in Poland, offers insight into the user’s exposure to carcinogenic carbonyls.

The e-liquids used in e-cigarettes are primarily composed of glycerin and propylene glycol. We set out to find out what chemicals are generated during use of e-cigarettes, particularly at variable voltages. Some devices allow the user to adjust the voltage to increase vapor production and nicotine delivery.

We found that when e-cigarettes were operated at lower voltages, the vapors that were generated contained only traces of some toxic chemicals. These chemicals included the carbonyls formaldehyde, acetaldehyde, and acetone. However, when the voltage was increased, the levels of these toxicants also significantly increased.

The novel finding of our study is that the higher the voltage, the higher the levels of carbonyls. Increasing battery output voltage leads to higher temperature of the heating element inside the e-cigarette. Increasing the voltage from 3.2 to 4.8 volts resulted in increases of anywhere from 4 times to more than 200 times the exposure to formaldehyde, acetaldehyde and acetone. The levels of formaldehyde in vapors from high-voltage devices were similar to those found in tobacco smoke.

Is the Electronic Health Record Defunct?

Jun 30, 2014• 28

By JEROME CARTER , MD

When building software, requirements are everything.

And although good requirements do not necessarily lead to good software, poor requirements never do. So how does this apply to electronic health records? Electronic health records are defined primarily as repositories or archives of patient data. However, in the era of meaningful use, patient-centered medical homes, and accountable care organizations, patient data repositories are not sufficient to meet the complex care support needs of clinical professionals. The requirements that gave birth to modern EHR systems are for building electronic patient data stores, not complex clinical care support systems–we are using the wrong requirements.

Two years ago, as I was progressing in my exploration of workflow management, it became clear that current EHR system designs are data-centric and not care or process-centric. I bemoaned this fact in the post From Data to Data + Processes: A Different Way of Thinking about EHR Software Design. Here is an excerpt.

Do perceptions of what constitutes an electronic health record affect software design? Until recently, I hadn’t given much thought to this question. However, as I have spent more time considering implementation issues and their relationship to software architecture and design, I have come to see this as an important, even fundamental, question.

The Computer-based Patient Record: An Essential Technology for Health Care, the landmark report published in 1991 (revised 1998) by the Institute of Medicine, offers this definition of the patient record:

A patient record is the repository of information about a single patient. This information is generated by health care professionals as a direct result of interaction with the patient or with individuals who have personal knowledge of the patient (or with both).

Note specifically that the record is defined as a repository (i.e., a collection of data). There is no mention of the medium of storage (paper or otherwise), only what is stored. The definition of patient health record taken from the ASTM E1384-99 document, Standard Guide for Content and Structure of the Electronic Health Record, offers a similar view—affirming the patient record as a collection of data. Finally, let’s look at the definition of EHR as it appears in the 2009 ARRA bill that contains the HITECH Act:

ELECTRONIC HEALTH RECORD —The term ‘‘electronic health record’’ means an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff. (123 STAT. 259)

Even here, 10 years later, the record/archive/repository idea persists. Now, back to the issue at hand: How has the conceptualization of the electronic health record as primarily a collection of data affected the design of software systems that are intended to access, manage, and otherwise manipulate said data?

Killer Features of the Next EMR

Jun 29, 2014• 18

By CRAIG MONSEN

I was absent-mindedly playing with my iPhone today and took special notice of a feature I have rarely used before. If you swipe all the way to the left on the home screen, you will get a search bar to search all of your iPhone. This includes contacts, iMessages, and apps. I’ve never needed to use this before—a testament to the iPhone’s ease of use. Just prior to this, I was working on some patient notes using my hospital’s electronic medical record (EMR). In contrast, each task I performed required a highly-regimented, multi-click process to accomplish.

Criticizing EMR interfaces is a well-loved pastime among clinicians. Here, however, I am going to take an oblique approach and reflect instead on what has made good interfaces (all outside of medicine, it turns out) recognized as such.

Speed

The Google Algorithm often gets credit for Google winning the Great Search Engine War. Indeed, there are whole teams dedicated to improving it. However, if you compare algorithms today, even 5 years ago, the differences in results have been only marginal. How does Google stay ahead? Speed. Google has done extensive research to determine what keeps users coming back and it is unequivocally speed of results. It has been much of the motivation for creating their own browser (Chrome) and operating system (Android). Speed means more searches and more searches means more money for Google.

Search

With EMRs, wait times to store and retrieve data can be extremely long. Moreover, it frequently takes multiple clicks to get to the precise page you want, further compounding the problem. But how slow is slow? Research in web user behavior indicates that 47% of consumers expect a web page to load in 2 seconds or less and that 40% of people abandon a website that takes more than 3 seconds to load. It regularly takes over 3 seconds to retrieve an important piece of data from an EMR. That makes the experience constantly frustrating; I wish there was another EMR I could switch to. (As a fun aside, I often find myself logging into two computers side-by-side in the hospital to save precious seconds waiting for the computer to load.)

What Would You Do If You Were Me?

Jun 28, 2014• 25

By NORTIN HADLER, MD

“Effectiveness” is at the forefront of the health policy debate. Effectiveness is the assessment of whether any particular medical intervention actually advantages patients when prescribed in practice settings. To be considered effective, the intervention must result in a clinically meaningful improvement for an adequate percentage of patients. Furthermore, it must not result in a clinically important adverse outcome in too many. Clearly, “effectiveness” is a value-laden construct. How is “meaningful improvement” defined and by whom? How is “important adverse outcome” defined and by whom? How are “adequate percentage” and “too many” defined and by whom?

“Cost-effectiveness” is even more value-laden. It is legislated to be off-the-table in the machinations of the Affordable Care Act for reasons that vary from fear of rationing to fear of compromising profit margins. But no one can exclude cost-effectiveness from the patient-doctor dialogue. Considerations of co-pays and deductibles often weigh heavily in the valuation of interventions.

The greatest advance in clinical medicine in my time in the practice, fast approaching 50 years, is that today patients and their doctors can assess effectiveness as collaborators. No longer does an imperious pronouncement by a physician suffice. Rather, the patient should occupy the driver’s seat with the physician as navigator. For each option in intervention, the patient asks, “Based on the available science, what is the best I can expect?”

For nearly 50 years, no prescription drug could be marketed unless the FDA was convinced that it had a tolerable benefit-to-risk ratio based on scientific studies. The bar for devices (like hip replacements) and procedures (like liposuction) is not as high, but there is usually some informative clinical science of this nature. The science is generally designed in the hope of demonstrating a favorable benefit-to-risk ration. Hence, patients and interventions are chosen to measure outcomes in the best case. However, make no mistake; neither the fact of FDA approval nor common practice is an adequate response to “What is the best I can expect?” If the best case falls short in your mind, why would you acquiesce to the intervention?

Disrupted: How Computerization Is Changing the Practice of Medicine In Surprising Ways

Jun 28, 2014• 39

By BOB WACHTER, MD

Bob Wachter

The following is an excerpt from the preface of my new book, which is tentatively titled: “Disrupted: Hope, Hype and Harm at the Dawn of Medicine’s New Age.” Author’s note and request to THCB readers.

If you’re a 24-year-old who does not plan on getting sick for the next couple of decades, this is probably not the ~~book~~ blog post for you.

By the time you need our healthcare system, it will be wired in ways we can’t imagine today. By then, computers will have transformed healthcare – as they already have retail, publishing, photography, and travel – leaving it better, safer, and maybe even cheaper. Most of the kinks, perhaps other than what our society will do with boatloads of unemployed dermatologists, radiologists, and hospital administrators, will have been ironed out. I hope to live to see this day myself. It’ll be, as my kids say, hecka cool.

But for the rest of us – both those who need our medical system today and those who currently work in it – the path to computerization will be strewn with landmines, large and small. The challenges are everywhere. Medicine, our most intimately human profession, is being dehumanized by the entry of the computer into the exam room. While computers are preventing many medical errors, they are also causing new kinds of mistakes, some of them whoppers. Sensors and monitors are throwing off mountains of data, often leading to more cacophony than clarity. Patients are now in the loop – many get to see their laboratory and pathology results before their doctor does; some are even reading their doctor’s notes – yet are woefully unprepared to handle their hard-fought empowerment.

In short, while someday the computerization of medicine will undoubtedly be that long-awaited “disruptive innovation,” today it’s often just plain disruptive: of the doctor-patient relationship, clinicians’ professional interactions and workflow, and the way we measure and try to improve things. I’d never heard the term “unanticipated consequences” in my professional world until a few years ago, and now we use it all the time, since we – yes, even the insiders – are constantly astonished by the speed with which things are changing and the unpredictability of the results.

Before we go any further, it’s important that you understand that I am all for the computerization of healthcare. I bought my first Mac in 1984, back when one inserted and ejected floppy disks so often (“Insert Excel Disk 2”) that the machine felt more like an infuriating toaster than a sparkling harbinger of a new era. Today, I can’t live without my MacBook Pro, iPad, iPhone, Facetime, Twitter, OpenTable, and Evernote. I even blog and tweet. In other words, I am a typical, electronically overendowed American.

And healthcare needs to be disrupted. Despite being staffed with (mostly) well trained and committed doctors and nurses, our system delivers evidence-based care about half the time, kills a jumbo jet’s worth of patients each day from medical mistakes, and is bankrupting the country. Patients and policymakers are no longer willing to tolerate the status quo, and they’re right.

What JCAHO Knows

Jun 26, 2014• 17

By KAREN SIBERT, MD

Here’s a doctor’s health tip for patients that I’ll bet you haven’t heard before.

If you’re a patient who walks into a hospital for an elective procedure of any kind–surgery, or a diagnostic test–and you find out that Joint Commission reviewers are on site, reschedule your procedure and leave. Come back another day, after the reviewers have left.

Why? Because every single person who works there will be paying a lot of attention to Joint Commission reviewers with their clipboards, and scant attention to you.

The Joint Commission has the power to decide whether the hospital deserves reaccreditation. Administrators, doctors, nurses, technicians, clerks, and janitors will be obsessed with the fear that the reviewers will see them doing something that the Joint Commission doesn’t consider a “best practice”, and that they’ll catch hell from their superiors.

For you as a patient, any idea that your clinical care and your medical records are private becomes a delusion when the Joint Commission is on site. Their reviewers are given complete access to all your medical records, and they may even come into the operating room while you’re having surgery without informing you ahead of time or asking your permission.

Perhaps physicians and nurses have an ethical duty to inform patients when the Joint Commission is on site conducting a review. Right now, that doesn’t happen. Does the patient have a right to know?

Unintended consequences

How did any private, nonprofit organization gain this kind of power? Why do American healthcare facilities pay the Joint Commission millions each year for the privilege of a voluntary accreditation review? It’s a classic tale of good intentions, designed to improve healthcare quality, that turned into a quagmire of unintended consequences and heavy-handed regulation.

American surgeons in 1918 started a system of reviewing hospitals because they were rightly concerned about serious differences in quality of hospital care and standards of practice. They wanted to evaluate hospitals objectively and motivate substandard ones to improve. In 1951, the American College of Surgeons joined forces with the American Medical Association, the American Hospital Association, and other corporate members to form the Joint Commission for Accreditation of Hospitals (JCAH).Continue reading…

Breaking: Health 2.0 Fall Conference Lineup Is Out!

Jun 25, 2014• 1

By SOPHIE PARK

Tech giants storming the digital health landscape will be center stage at Health 2.0’s 8th Annual Fall Conference in Santa Clara, CA. An impressive line-up of health and tech executives headline three full days of live demos and innovative sessions. Highlights include keynotes from visionary physicians Eric Topol and Patrick Soon-Shiong as well as Samsung Electronics President, Young Sohn in conversation with Health 2.0 CEO, Indu Subaiya. Leaders from Intel, Humana, IBM Watson, Qualcomm Life, Merck, athenahealth, eClinicalWorks and the Office of the National Coordinator for Health Information Technology (ONC) will showcase and discuss their latest technologies and initiatives on the main conference stage this fall. As always, Health 2.0 features over 150 live demos of new technology, 250+ speakers, 50+ sessions, more networking, and deals-done than anywhere else in health technology.

The main stage will feature the following panels:

Smarter Care Delivery: Amplifying the Patient Voice: Matthew Holt, Co-Chairman of Health 2.0, sparks the discussion on how new technology platforms, payors, and providers are working together for enhanced patient care delivery and engagement.

Consumer Tech and Wearables: Powering Healthy Lifestyles: Bringing together the most innovative wearables that are pushing individualized medicine into the future, Indu Subaiya, CEO of Health 2.0, leads this session focused on how consumers are experiencing new lifestyles centered around technology. Don’t miss the live fashion show featuring all the latest trends in digital health wearables!

Buy, Sell, Exchange: New Markets for Consumers, Employers, and Providers: Nearly a year after ACA implementation, this session will dive into the new ways benefits are being offered to consumers, how employers are buying care directly, and what new technologies are enabling change in direct care provision.

Data Analytics: From Discovery to Personalized Care: This panel focuses on how data analytics and powerful visualizations are pushing forward clinical research. Highlights will include genomics, non-invasive diagnosis tools, and integrated data collection are uncovering new discoveries, promoting personalized medicine and new care protocols.

Returning crowd favorites include 3 CEOs … (and a President!), The Unmentionables hosted by Alexandra Drane, The Frontier of Health 2.0 hosted by David Ewing Duncan, and Launch! with ten brand new companies unveiling their products for the very first time! Many more sessions and panels can be found on the Health 2.0 online agenda.Continue reading…

PCORI Works to Deliver the Comparative Evidence Health Care Stakeholders Need

Jun 25, 2014• 2

By JOE SELBY, MD

At the Patient-Centered Outcomes Research Institute (PCORI), we believe comparative clinical effectiveness research (CER) is important and that we have a critical role to play in establishing the nation’s CER priorities. I’m pleased to say that many respondents to the latest National Pharmaceutical Council (NPC) survey think so as well.

While results of CER studies that we and others are funding have yet to be completed, and CER’s ultimate ability to transform our healthcare system is still years away, nearly all respondents in this fourth annual survey agree that CER is here to stay and that it will become increasingly important in aiding decision making. Respondents also indicated that CER has not yet assessed the broader array of outcomes that matter to patients.

These are important insights. The survey tracks the attitudes of researchers, policymakers, employers, business groups, insurers, and health plans. Engaging with these stakeholders – along with patients, caregivers, clinicians, and other providers – and ensuring that the work we fund provides evidence they can trust and use, are essential if CER is to realize its potential in guiding health care.

That’s why Congress authorized PCORI’s establishment as an independent, non-profit organization focused on ensuring that the broad healthcare community is meaningfully engaged in our work. We’re governed by a diverse board that represents all stakeholders. And through an open and collaborative approach to research, we’re identifying the questions patients and other clinical decision makers need answered, so they can make better-informed choices that will lead to better outcomes.

We’ve already awarded $464.4 million to support 279 studies that advance patient-centered CER and we expect to commit another $1 billion over the next two years.

Physicians Interactive Acquires MedHelp In Move to Bridge Consumer and Provider Worlds

Jun 25, 2014

By Kim Krueger

Earlier this week, Health 2.0 promised some big news showing how the provider and consumer facing worlds of Health 2.0 are coming together. Today, they officially shared that Physicians Interactive has acquired MedHelp. Both companies are stalwarts in the Health 2.0 world, and their merging serves as further evidence that consumer and professional facing tools are continuing to connect in new and meaningful ways.

Physicians Interactive has been onstage at Health 2.0 multiples times, but always in a professional facing role. Tools like Omnio, a provider-to-provider content sharing app, play to Physicians Interactive strengths, which center on accessing and communicating with an extensive provider network — some 300,000 doctors to be exact.

MedHelp, on the other hand, another Health 2.0 staple, is nothing if not a consumer-oriented tool. Their web-based online health community helps individuals actively manage their health with a host of tools, including patient forums, physician search engines, provider communication tools, and personalized trackers.

MedHelp has grown organically (CEO John deSouza always tells us “no bought traffic”!) and gone from communities to trackers to an active health data utility layer that takes in data from many devices and trackers. In one recent partnership, demoed at Health 2.0 last fall, MedHelp took a step towards connecting consumers and providers with an app that delivers both lab results and an expert opinion, if the consumer elects to receive one. However, connecting to providers was still on the edges of MedHelp’s capabilities.

Where Are The Hot Spots For Antibiotic Resistance?

Jun 24, 2014• 16

By TOM FRIEDEN, MD

In July, CDC will roll out a new way every hospital in the country can track and control drug resistant bacteria.CDC already operates the National Healthcare Safety Network (NHSN), with more than 12,000 health care facilities participating. Now we are implementing a breakthrough program that will take control of drug resistance to the next level – the Antibiotic Use and Resistance (AUR) reporting module. The module is fully automated, capturing antibiotic prescriptions and drug susceptibility test results electronically.

With this module, we’ll be able to create the first antibiotic prescribing index. This index will help benchmark antibiotic use across health care facilities for the first time, allowing facilities to compare their data with similar facilities. It will help facilities and local and state health departments as well as CDC to identify hot spots within a city or a region.

We’ll be able to answer the questions: Which facilities are prescribing more antibiotics? How many types of resistant bacteria and fungi are they seeing? Do prescribing practices predict the number of resistant infections and outbreaks a facility will face? Ultimately with this information, we’ll be able to both improve prescribing practices and identify and stop outbreaks in a way we have never done before.

This will help deploy supportive and evidence-based interventions at each facility as well as at regional levels to help stop spread among various facilities.

The need for a comprehensive system to collect local, regional, and national data on antibiotic resistance is more critical than ever. The system now exists, and we need quick and widespread uptake.

Rapid and full implementation of this system is supported through the proposed increase of $14 million contained in CDC’s 2015 budget request to Congress.

With the requested funding increase in future years, CDC would look to develop web-based tools and provider apps so physicians will gain access to facility- and community-specific data via NHSN on the most effective empiric antibiotic for the patient in front of them. For example, a physician in a burn unit treating a patient with a possible staph infection will know what antibiotics that particular microbe is likely susceptible TO and which ones are likely to be most effective.

Instead of broad-spectrum antibiotics being the default choice, as is often the case now, doctors will see recommendations for targeted narrow-spectrum antibiotics that are more likely to be effective and less likely to lead to potentially deadly infections such as C. difficile.