Sharing of IT Data: Shaping Up and Moving Ahead
Continuing its efforts to push us forward, HHS has proposed a program that will enable hospitals and healthcare organizations to legally share electronic prescribing EHR tools and data with doctors that work outside the hospital. Currently there are specific legal barriers which prevent this IT sharing.
A planned certification group will be appointed to monitor the system’s ability to accomplish two essential goals: seamlessly and easily share essential healthcare and insurance data - while scrupulously guarding patients’ rights and privacy. At the same time, systems would self-monitor whether any party -- hospital, physician or program provider -- uses its facilities unfairly for personal financial gain. HHS has awarded three contracts -- totaling $17.5 million -- to create quickly-as-possible prototypes that would develop, test and evaluate these methods and standards. In the scheme of things, it is a small but important amount.
Meanwhile and working on their own - dozens of hospitals, insurers and physicians groups across the country are reportedly taking initial steps in forming Regional Health Information Exchanges -- more often simply referred to as RHIOs or “data exchanges” -- that can make it all happen better and faster. A number are well into pilot projects.
Recent example is in San Diego, where the area’s medical society has launched a project -- the San Diego Medical Information Exchange -- aimed at electronically linking 35 hospitals and 7,000 area physicians. The CEO of the foundation admits it is a tough and uphill battle simply because productivity is expected to drop for a minimum of six months after installation as the system gets rid of the “bugs” and the members and employees get used to working with the changeover. But the promised down-the-road financial and information advantages are expected to hopefully repay the effort many times over for many, many years.
It has taken the data exchange in nearby Kansas City, Mo. over three years to get an RHIO pilot program started, but it promises to have that program up and running soon after the new year. Development is being funded by a chain of nine area hospitals and the area’s Blue Cross/Blue Shield. The initial goal is to get up-and-running a system that will electronically validate insurance coverage, then move quickly on to claims processing.
A year-old Tennessee RHIO -- the MidSouth eHealth Alliance-- seems to be a little ahead of the game, thanks to a $5 million start-up grant from the feds, backed by double that amount from the state. It covers just three counties, but includes cooperating partners in hospitals, physicians practices, insurers and univer-sities. Its pilot program began to run in late summer.
Deciding to not merely sit and wait, the Tennessee organization has also initiated a plan to offer similar services to other regions. And a vendor partnership -- CollaboraCare -- a variety of IT products and services is in the early stages of building pre-packaged integrated components that will generally facilitate information exchange opportunities. Reportedly they are currently talking to two dozen RHIOs that are in their early-forming stage.
Best estimate is that perhaps a dozen pilot and test RHIO programs are currently in-works - with hundreds of others literally on the drawing boards.
Still far from satisfied, the government just recently awarded a contract to a working partnership of George Washington University, Mass General and the Institute for Health Policy to gauge and report on the level of adoption of EHR across the country. It will cover the usual areas -- hospitals, multi-practice physicians and insurers -- and will also go a bit far afield and attempt to chart some basically-unchartered territory - such as availability and use of electronic prescriptions and use of EHR by individual practitioners. This is a planned long-range program, with the first report anticipated in the fall of 2006.
Fiscal Reality Setting In
California’s highly-respected RAND Corp. recently released a study, which appeared in the journal Health Affairs, that is a sad answer to all those people who say, “We have to do something about the high cost of healthcare”. RAND states that technological innovations in place and easily-imaginable in the near future will sharply increase length-of-life (which of course is good) , but will sharply add to the present “high cost” of healthcare (which of course is bad). As examples, they presented brief views of ten medical technologies that are anticipated in the coming two or three decades. All will extend life. Most will eliminate at least some degree of suffering. All will cost a lot of money!
RAND used a computer model representing about 100,000 Medicare beneficiaries to reach these conclusions. They also incorporated information about younger Americans into their computer model; this is to enable researchers to factor in anticipated need-for-care for the next generation of oldsters.
Their prime example is something “small” - expanding the use of miniaturized and more-precise implantable defibrillators, life-savers for a huge additional number of older people with serious heart conditions. These alone were estimated to increase cost-of-care by $14 billion a year.
A preventive treatment for Alzheimer’s disease and a variety of cancer-fighting drugs were cited as being in “active research” but could possibly increase costs of caring for older and older Americans by a low of 14% to a stratospheric high of 70% - depending on where the studies lead us. They even factored in the additional cost-of-care if scientists discovered “a pill” to extend life, something they see as at least possible because of the rapid expansion of our scientific expertise.
RAND found one way to save...get obesity under control for older Americans. They estimated that could save close to $40,000 in care per patient that brings his or her weight to a more-normal range. They saw it as a hope, not a scientific certainty.
In answer to all these fiscal negatives was a hopeful in-part “dream” solution offered by a Harvard dean; that among the new inventions could be a new generation of interventions that would enable caregivers to do what they do now, but do it more economically. Example given was a still-to-be-defined form of cardiac intervention that just possibly would be simpler, easier and less-costly than angioplasty.
While this debate was heating up, the head of the National Cancer Institute forecast that, by 2015, the major suffering and premature death due to cancer will be brought into line, making cancer a much more manageable disease and extending both life and the quality of that life. But, of course, at great cost. Others found this projection a bit premature, but attainable somewhere in the almost-forseeable future.
Bad Mix, Not Enough Match
Canada’s once-envied national health system continues to show additional signs of fiscal and bureaucratic strain. Latest admission is that they simply can’t produce enough specialists to meet the needs of their people - because there aren’t enough residency programs in the fields that newly-graduated MDs are looking to enter. This in the face of an impending record retirement -- close to 4,000 in the next two years -- of older doctors.
For example, though the need keeps expanding, there are currently only 1,508 residencies available nationwide. Just 49 for diagnostic radiology, 6 for dermatology, 18 for ENT, 27 for ER training, small but unreported numbers for urology and ophthal-mology. The competition is fierce, with newly-graduated MDs often also facing last year’s grads who are trying again.
There are two major reasons for all this. First, provincial governments finance these positions and they simply do not have the money to fund more residencies. Secondly, more of these new MDs are opting for fields -- like the above -- that are relatively free of middle-of-the-night emergen-cies and permit a more-stable personal lifestyle.
So the great number end up settling for a field that is not really their choice; which results in yet another problem. At least twenty important subspecialty programs at ten Canadian medical schools don’t have a single participant! These include advanced training in pediatric kidney disease, cancer care, geriatrics, adult rheuma-tology, vascular surgery, pathology and high-risk pregnancy care.
"Swapping" Kidney Donors
Update. A Living Donor Kidney Exchange Program -- which started small and personal in 2001 -- is now expanding rather rapidly and taking on organizational proportions. Programs have been established in Ohio, New England and at both John Hopkins and the University of Chicago Hospitals. A cooperating program was launched at the end of summer by the NYC Organ Donor Network. Cooperating programs are being considered in New Jersey and Upstate New York. They currently exist in the Netherlands, Korea and Mexico.
The program is complex, but the method is simple. Two people -- each unaware of the other -- volunteer to donate a kidney to a specific friend or relative, but are rejected because there is biological incompatibility between the donor and their chosen recipient. So each donor most likely bows out of the program.
Now there is a second chance. A Kidney Exchange is contacted and uses its files and resources to “pair” a match. Each donor gives his or her kidney to the other’s selected recipient; a person they don’t know and never met, but someone with the essential matching biologicals. In other words. the donors trade recipients. Effectively overcoming the “impossible” non-match problem; accomplishing both donors’ goals and saving both patients’ lives. The two transplants are performed simultaneously.
"Surfing" for Donors
Parallel to the above story, another -- more-broad-based -- donor program is rapidly expanding across the Internet. In a frantic effort to get their name to the head of long lists, patients in need of transplants are setting up or subscribing to web sites - or even use chat rooms to tell of their need, their plight and to state the reasons why they should be the recipient of a life-saving organ transplant. Some of these sites are personal, others -- such as MatchingDonors.com, which claims to be non-profit -- charge rather large fees for listings.
The United Network for Organ Sharing, the nonprofit organization that currently oversees the nation’s procurement program -- and basically solicits for these donated organs -- are not amused, though they see a possibility for sharply-increased awareness of the need. But also see their key elements -- fairness, equality and anonymous donations -- being trampled on as people with Internet savvy and maximum financial resources can manage to move themselves to the head of the line -- while others literally die waiting.
Still others say we are effectively turning human organs -- or parts of a liver or lung -- into salable items, almost Ebay style.
Most transplant centers now refuse to perform privately-arranged procedures; a few will perform the operation but only after intense screening of both parties.
State-of-the-Art IT
According to a recent article in the British medical journal The Lancet, Personal Digital Assistants, which are really adaptations of Palm Pilots, are on-track to becoming the indispensable portable medical data-delivery system of the future - by literally putting patient data, drug information and treatment records at the doctor’s fingertips.
Extended bandwidth of cellular telephone networks or high speed wireless institutional networks in hospitals -- each clearly foreseeable in the near future -- will enable doctors to bring up patients’ x-ray data, charts and medical information wherever they or the patient may be in an emergency situation.
Pilot Project: "Smart eCards"
The test is small as you can get but it is paving the way for an entire country to switch over to electronic health data cards, hopefully in just a few years.
A month or so ago, the IT service division of Germany’s Deutsche Telekom AG began a test that involves just fifty patients, three doctor’s offices and a hospital in the modest-sized city of Bottrop. The e-health card contains a chip for storing personal data about the patient as well as key medical information in case of an emergency. Much of the actual data will initially be stored on a central server at the hospital but, when the program is expanded, will eventually be contained at an outside data center.
Each of the fifty participating patients were issued personal electronic health cards; their doctors received compatible e-professional cards. Both cards are needed to activate the file, either in the doctors’ offices or at the hospital. Doctors are also able to electronically prescribe and sign prescriptions.
It is anticipated that the system will quickly move to an advanced test stage and will be serving 20,000 patients and 75 physicians by March 30. If all goes as planned the program will continue to roll out, covering Germany’s 70-million people soon after 2010.
National Children's Study Planned
The most-ambitious analysis and monitoring of American’s children will come off the drawing boards in 2006 and is scheduled to begin enrolling youngsters the following year. The plan is to eventually follow more than 100,000 participants from the womb to adulthood. It will all start with pilot programs in six counties across the United States, locally including Montgomery County, Pa. and Queens County, N.Y. It is planned to eventually include children from 105 counties across the country.
The study’s goal is to literally cover everything that affects a child’s growth and health - family and economic relationships, diet, medical care. Projected cost is $2.7 billion over a 25-year period. The reported ultimate goal is first to prevent disease and to therefore in some tangible way increase the “wellness factor” of all of America’s children - regardless of location, race, religion and economic conditions.
Both pregnant and non-pregnant women will also be asked to participate - in order to additionally analyze lifelong health factors, some of which actually pre-date conception of the subjects in the study. Initial results to be released in 2010.
CaringBridge Connects
It all started in 1997 when a computer-savvy group of friends created a web site to update the condition of another friend having a difficult pregnancy/delivery. It posted daily news about the patients’ conditions and left room for lots of good wishes to flow back.
Today CaringBridge.org offers -- free -- information, guidance and instruction on how to quickly and easily set up an individualized website within their system. Following clearly-stated and strict privacy rules. The “designer” is also given a choice of available site styles and a checkoff listing the patient as newborn, child, teen or adult.
There are currently 35,000 CaringBridge sites in operation. That is a 75% increase in just the past year. Faster and easier than e-mail and phone calls, especially if the patient is in the hospital. Though it is free to participants, CaringBridge has to generate some money someplace and one way is through the sponsorships of health-related organizations. Three New Jersey hospitals recently signed on.
This fall’s hurricanes led to an extension of the program. They have now added a CaringBridge Relief Site to help connect disaster survivors with friends and family.
Plaque-Shaving Medical Razors
Latest news from the world of Wonder Medicine - a razor small as a grain of rice that opens clogged leg arteries from the inside. Clogged leg arteries have historically been more difficult to alleviate than even clogged heart arteries.
Peripheral Artery Disease, or PAD, is an insidious illness that afflicts at least twelve million Americans by depositing a plaque-like substance inside leg arteries, causing them to stiffen and narrow until the needed blood flow thins to a trickle. The pain it causes is intense, constant and debilitating. The disease results in an average 150,000 amputations a year. It also increases the patients’ risk of heart attack and stroke seven times over, because clogged leg arteries often lead to other clogs in other places, stifling some of the body’s overall need for constant blood supply.
Till now standard methods of angioplasty haven’t worked over reasonable periods because normal stents simply aren’t long-lasting in this area of the body.
Now comes the tiny razor -- with the non-medical name of SeaHawk -- that is threaded into a catheter directed to the blockage. Then the blade emerges and begins “shaving” away plaque, which is collected and gently removed. To date 335 patients have received the procedure, with 79% claiming complete relief, at least in the near term.
And there is a bonus, too. A drug company reportedly has purchased the surgically-removed plaque - and is using it in an attempt to find ways to eliminate this arterial buildup.
Rethinking…
The benefits of living wills have been impressed on most of us since the first one was created in 1969, when newly-developed high-tech medicine made it increasingly possible to keep fading patients alive for extended periods. In 1990 Congress passed a law requiring hospitals to provide patients with information about living wills.
At first, a number of doctors, lawyers and medical ethicists favored them, many most-vocally. Now serious questions are arising about their worth and value. Problem is that most living wills seem either too-broad or too-limited; this because no one knows the exact conditions that will be in effect when a life-or-death decision may be required.
Last fall, the President’s Council on Bioethics issued a report on “Caregiving in America” and reached the conclusion that, as a general rule, living wills were both limited and flawed instruments, mainly because in later life the signer of that living will -- even in the face of diminished capacity -- may really want to push impending death further into the future.
Gaining favor as a replacement document is the “Healthcare Proxy”, which designates someone to speak for patients if they cannot speak for themselves. Rather than supplying blanket authorization to this person, the document can list dozens of possible conditions that may develop in later years and signify specific actions that can be taken in each case. You might call it pinpoint rather than umbrella rules. But it seems about to become the basis of another big battle about this difficult problem.
Medical Minutia
Scottish-born Dr. John Hunter, though apparently little-remembered is considered by many as one of the three greatest surgeons of all time. (The others were the more-famous Joseph Lister and Ambrose Pare.)
Before Hunter, English surgery was thought of merely as a “technical trade”, bound by constant discussion and too-little imaginative effort. Hunter effectively changed all that by insisting on experimentation and “hands-on” surgical efforts. He spent twenty-five years getting these points across as an instructor of anatomy and surgery at London’s most-respected hospitals of that time.
His most famous quote: “Don’t think; try!”
Transcription Tips
Temperature is expressed in numerals except for “zero.” Use “minus” (not the symbol) to indicate temperatures below zero. Use the degree symbol (?) with the abbreviation for the scale used (F for Fahrenheit, C for Celsius and K for Kelvin). If the symbol is not available, spell out “degrees;” “degs” is NOT an acceptable abbreviation for degrees.
Do NOT mix symbols with spelled out words. Celsius is the preferred scale name to “centigrade scale.” Do NOT use a period after a temperature scale abbreviation.
CORRECT FORMS: zero degrees; 98.6?F: 38 degrees Celsius: minus 1 degree Kelvin
INCORRECT FORMS: 0?F; 38?C.; -1?F; 1 deg K
Auditing the News
Researchers in two seemingly unrelated fields -- heart conditions and migraine headaches -- are starting to see common ground, much to the surprise of all. Just possibly up to half of all migraine cases may be caused by a heart defect -- literally a small hole that was thought harmless -- which allows blood to pass from the right atrium to the left, bypassing a normal filtering process. This in turn allows small clots to reach the brain, where it can cause migraines and even a stroke.
Last year a study monitored fifty migraine patients who had undergone surgery to close this small hole. More than half reported total cessation of migraines and seven noted a marked reduction in their attacks.
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Some kind of award for “outside the box” thinking should go to Children’s Hospital, Florence, Italy. According to a recent article in Pediatrics, a clown was brought in during 40 procedures in an attempt to distract the patients -- each under three years old -- prior to relatively-minor but obvious anxiety-causing operations. The short performance lasted until each child was put under anesthesia.
However - it didn’t work! The idea never got beyond this small test, simply because the staff concluded the clowns interfered with their more-important medical duties; thereby putting the children at additional risk.
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Deserved self-acclaim from Sentra Healthcare of Norfolk Virginia for an eICU system, which permits doctors to remotely and constantly monitor many patients from one central location. The system was originally installed five years ago.
The eICU is credited with reducing intensive-care deaths by 20% - and, as a financial bonus, is also credited with returning 155% percent on its cost of installation.
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This winter’s supply of cough and cold medicine should offer quite a change. Same brands, same promises, but lots of new and easier ways to take your dosages. Pocket-sized throat spray, freezer pops, and strips of meds that melt in your mouth are just a few of the innovative new methods that have recently made it to market. Most cost only pennies more, but go down so much smoother!
Personal caution: since the new packaging may alter the dosage, be sure to read the label.
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Long known is the existence of human proteins which recognize foreign objects -- viruses and bacteria -- and activate the immune system to fight back. Now a new generations of scientists are attempting to create drugs that will activate these “sentinels” on demand and in advance - to make the immune system preempt an attack by the likes of cancer, hepatitis and other major diseases.
Various vaccines have been used for years against a host of diseases. But these always were narrow-range and usually used against most-specific one-time strikers (flu shots, for example). The giant possibilities of this new approach has bought broad-backing and huge investments from major companies led by Pfizer. Currently, there are initial-stage trials across a broad spectrum - but it is simply too early to tell if these “medical miracle” dreams will come true.
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Putting things into perspective: This could go down as the medical records quote of the year. It’s accredited to David Brailer, MD - National Coordinator for Healthcare Technology and a man widely-respected for his careful planning and incisive thinking.
“I’m the president’s senior adviser on health information technology and when I get an EOB (explanation of benefits) for my 4-year old’s care, I can’t figure out what happened or what I’m supposed to do.”
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Most-basic lab tests (of cultures) at Penn State’s College of Medicine found that a common and non-disease causing virus called AAV2 killed cervical, prostate, breast and squamous cell cancers in less than a week. AAV2 infects the majority of the population and has no known ill effect on normal cells. However, it will be close to a decade before it passes all the more-difficult tests and -- if continually successful -- can be put to work for us.
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A Harvard research group has come up with the latest reason for fighting many types of cancer -- particularly breast cancer -- by reducing intake of fat while increasing level of exercise. This based on a review of the charts of 3,000 RNs diagnosed with early breast cancer between 1984 and 1998. Their charts were followed until 2002. The patients who regularly exercised -- jogging, walking, calisthenics, even playing golf -- three to five hours a week cut their risk of being prematurely felled by the disease by 50%. An important guideline, since women diagnosed with breast cancer normally decrease their physical activity by about two hours a week.>>>>>>>>>>>>>>
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