Health Information Exchange

Patient Engagement Requires Right IT Tools

noreply@blogger.com (Ben Littenberg) — Mon, 09 Jul 2012 12:11:00 +0000

Paul Cerrato, writing in Information Week, thoughtfully discusses how IT tools can help (or hinder) practices to engage patients in their care (and meet Meaningful Use requirements). He makes the point that engagement tools that look good in a controlled laboratory environment often fail when put into service in the messy day-to-day world of sick patients, anxious families, harried providers and overworked staffs. That's why it is critical to select tools that have proven themselves in large-scale, well-designed evaluations in real-world settings.

http://www.informationweek.com/news/healthcare/policy/240003073#

Managing chronic conditions through automated patient engagement

noreply@blogger.com (Ben Littenberg) — Thu, 05 Apr 2012 12:56:00 +0000

Thanks to the good folks at PhysBizTech for publishing my little screed on using health information to engage patients. Insomniacs among you can find it here.

Patient Engagement in the US and Abroad

noreply@blogger.com (Ben Littenberg) — Tue, 03 Apr 2012 11:36:00 +0000

Robin Osborne and David Squires from The Commonwealth Fund just published a survey of almost 19,000 patients from 11 developed nations (including the US) to see how engaged they are in their health care. The US scores were fair-to-middling, better than Norway, Sweden and Canada, but nearly as good as the UK and Switzerland.

Remarkably, the US did very well on "Follow-up and Support Between Visits" for patients with a chronic condition: 77% said they could easily call to ask a question or get advice and 31% said that their health care professional contacts them to see how things are going. Although 31% was the best of any of the countries, it is not a very good showing at all. Clearly, this is a big opportunity area both at home and around the world.

What good is being engaged? The more engaged patients are, the higher the reported quality of care and the less likely they are to experience a medical error. Coupled with other, prospective, evidence that engagement improves medical outcomes and lowers costs of care, and this is a very big deal, indeed.

Osborn R, Squires D. International Perspectives on Patient Engagement: Results From the 2011 Commonwealth Fund Survey. The Journal of Ambulatory Care Management 2012;35(2):118-28

You can read the article here.

Informatics for Consumer Health

noreply@blogger.com (Ben Littenberg) — Fri, 30 Mar 2012 00:06:00 +0000

Informatics for Consumer Health is a consortium of federal agencies seeking to empower providers to manage care and increase the ability of consumers to gain mastery over their own health. Their web site offers news on health informatics from the academic literature, upcoming events and funding opportunities. It seems directed primarily to academics and IT professionals, but health care providers and patients might find it useful as well.

Enjoy!

More care means lower costs?

noreply@blogger.com (Ben Littenberg) — Fri, 23 Mar 2012 01:04:00 +0000

The Commonwealth Fund recently published one of their very excellent issue briefs titled Paying More for Primary Care: Can It Help Bend the Medicare Cost Curve? by James D. Reschovsky, Arkadipta Ghosh, Kate Stewart, and Deborah Chollet. This paper reports on a simulation model of the effects of improving reimbursement for primary care services (as Medicare did last year). Based on data showing that more primary care leads to lower total costs via lower rates of hospitalizations and other expensive services, the authors conclude that "promoting primary care can help bend the Medicare cost curve."

Other than rationing, getting patients into primary care is just about the only known way to reduce utilization. There are many ways to increase use of primary care services (such as automated systems to increase engagement between patients and providers), but none of them will work if there aren't enough primary providers. There is clearly a shortage of primary care providers now and it will only get worse as demand grows in the future due to improved insurance coverage and an aging population. If primary specialties aren't made more attractive by increasing payments (and lowering administrative burdens, too, while we are at it), we will never see an end to the health care cost crisis.

Is Disease Management Dead?

noreply@blogger.com (Ben Littenberg) — Mon, 16 Jan 2012 21:43:00 +0000

Archelle Georgiou thinks so. Her very well-written post (on her own blog here and on Managed Care magazine here) is a thoughtful obituary. She puts the time of death last November, when the New England Journal published Nancy McCall and Jerry Cromwell's report on the CMS disease management pilot program (N Engl J Med 2011; 365:1704-1712). The various DM programs showed little or no benefit, but they cost CMS $400 million. Yes, I agree: disease management, as we know it, has bought the farm and ought to be buried.

Dr. Georgiou offers several quite cogent reasons for DM's failure. The most compelling is that DM as implemented has drifted from the format and target audience originally proven effective in clinical trials in the 1990's. Again, I think she is spot on.

What should we do to improve outcomes and reduce costs going forward? Many of the ideas being proposed appear promising, but have less of a justification than the currently-employed versions of DM have. We just wasted billions of dollars and many years by failing to use the evidence base correctly. It doesn't seem wise to me to abandon the requirement for solid evidence before we invest again. Rather, we should take steps to ensure that we use technologies and programs that are evidence-based AND that we employ them as close to tested as possible.

What are those technologies and programs? Classic disease management for heart failure patients has been proven effective many times and should be retained. Use of automatic systems to support chronic disease patients (and their providers) are very low cost and have also been proven in large randomized studies. Lowering co-pays and barriers to access for essential medications and services is another strategy with a large evidence base.

Let's not throw out the evidence-based baby with the DM bathwater.

The psychology of exchanging health information with patients

noreply@blogger.com (Ben Littenberg) — Wed, 23 Nov 2011 12:16:00 +0000

How does exchanging health information work to improve health? Getting the facts about your favorite subject (you!) is extraordinarily motivating. It is the reason why actionable communications like those embedded in effective patient outreach systems work. Here's a nice review of the psychology by Joe Kvedar at Connected Health: Self-Quantification as a Driver of Behavior Change

QR Codes for communicating with patients...

noreply@blogger.com (Ben Littenberg) — Wed, 21 Sep 2011 19:20:00 +0000

QR Codes are those funny little black and white squares that look like a checkerboard with a screw loose. They can contain a surprising amount of information. For instance, here is the URL for this blog:

If you scan this code with you phone, you will be directed ..... right back here. You can also do text. This one contains some words of wisdom from Mark Twain:

QR Codes are starting to be used in marketing (I've seen them on posters and flyers), but now that smart phones are so ubiquitous, they provide an option for sharing information with patients (an others). If you turn their medication list into a QR Code, they can scan it right into their smart phone and have it handy whenever. Here is a 6-minute video from the folks at Skyline Family Practice, in Front Royal, Virginia with some examples:

(http://www.youtube.com/watch?v=FSBIXSk4nbg for the non-scanning crowd)

Have fun scanning!

National Medical Home Summit

noreply@blogger.com (Ben Littenberg) — Fri, 16 Sep 2011 20:51:00 +0000

Benjamin Littenberg, MD,

Chief Medical Officer at
Patient Engagement Systems to Discuss Advanced IT for Primary Care at the National Medical Home Summit

The Fourth National Medical Home Summit, the Leading Forum on the Development and Implementation of the Patient Centered Medical Home, takes place Sept. 20-21 in San Francisco

Media Contact:

Christine Dunn

Savoir Media

(617) 484-1660

cdunn@savoirmedia.com

Burlington, VT - September 16, 2011 - Benjamin Littenberg, MD, Chief Medical Officer for Patient Engagement Systems, a health-care technology company that provides solutions for improving primary care for people with chronic diseases, will be presenting "Advanced IT for the Medical Home: Engaging the Patient" at the Fourth National Medical Home Summit in San Francisco later this month.

At the conference, Dr. Littenberg will discuss how information technology, when applied strategically and purposefully, can create engaged patients and be a key difference maker for PCMH efforts. Dr. Littenberg's presentation will include research that demonstrates that successful patient engagement improves outcomes and saves money.

"The future of healthcare is evolving and primary care delivery is changing, making engaging with patients more important than ever to the financial and clinical success of the primary care practice research. The Medical Home model will help this evolution happen, but the right information utilities need to be in place to engrain new methods of health improvement," said Dr. Littenberg.

Dr. Littenberg's Mini Summit presentation at the National Medical Home Summit will take place at 2:15 p.m. on Wednesday, Sept. 21. The Fourth National Medical Home Summit is being held on that day, as well as on Sept. 22, at the Grand Hyatt in San Francisco, California.

Patient Engagement Systems provides technology solutions that have been demonstrated to improve coordination, compliance and the overall management of chronic conditions by supporting physician decision-making and communication with their patients. Physicians who work with Patient Engagement Systems have found that the technology extended, and expanded, their capability to provide high-quality, cost-effective, and consistent medical care -- ultimately improving health outcomes and reducing expenses.

Patient Engagement Systems' technology is the only patient centered clinical solution that has demonstrated effectiveness in a National Institute of Health (NIH) funded study.

The National Medical Home Summit is the leading forum on the development and implementation of the patient centered medical home (PCMH). The Summit, a hybrid conference and Internet event that is sponsored by the Jefferson School of Population Health, will bring together the leading authorities and practitioners in the medical home field to discuss how the PCMH model is working, where it has proven outcomes, how it is evolving, and how it fits into plans for delivery system reform. The conference will present the key building blocks of the medical home model, and four major medical home themes -- IT, care coordination, patient engagement, and the medical home workforce. Each of these topics will be discussed in depth in separate mini summits.

For more information about the National Medical Home Summit, visitwww.MedicalHomeSummit.com

For more information about PES, visit www.patientengagementsystems.com

About Patient Engagement Systems®

Patient Engagement Systems® technology enhances patient engagement by fostering communication between patient and caregiver, and by delivering decision support to health-care providers. The PES system has been proven in a National Institute of Health clinical trial to improve health outcomes and reduce costs.

The patent-pending PES technology uses automated reminders, alerts, flow sheets and population reports to help health care providers better care for their patients, and patients better manage their chronic conditions. PES has been used by thousands of patients with diabetes in Vermont, New York, California and Texas. Clients include municipalities, private hospital systems, physician organizations, and managed care organizations. For more information about Patient Engagement Systems (PES), visit http://www.patientengagementsystems.com.

Webinar: Advanced IT for the Medical Home: Engaging the Patient

noreply@blogger.com (Ben Littenberg) — Fri, 16 Sep 2011 00:54:00 +0000

Advanced IT for the Medical Home:

Engaging the Patient

A special conference for senior executives & administrators from physician groups, emerging Accountable Care Organizations, health systems, Patient Centered Medical Homes, health plans, and government agencies.

To register for this interactive, 45 minute webinar, please click here.

System Requirements

PC-based attendees require: Windows® 7, Vista, XP or 2003 Server

Macintosh®-based attendees require: Mac OS® X 10.5 or newer

Answers to Your Specific Questions

If you have questions on our webinar and/or webinar formats, please contact us atmarketing@ptengage.com

Webinar Date: Monday, October 3rd

Time: 12:00 pm Eastern

Primary care is at the core of most every major initiative for health care reform - not the least of which is the Patient Centered Medical Home. The PCMH model will succeed or fail depending on how well primary care providers can engage their patients in a coordinated, continual, and directed pattern of care.

Information technology, when applied strategically and purposefully, can create engaged patients and be a key difference maker for PCMH efforts.

Benjamin Littenberg, MD FACP will share his experience as a practicing physician, academician, and information scientist about how primary care delivery is changing, and how engaging with patients is more important than ever to the financial and clinical success of the primary care practice.

Focused Discussion

Attendees will learn:

· How well the medical home model orients itself to patient engagement

· How primary care physician-lead groups have implemented technology solutions that support PCMH criteria

· What research and standard practices have established about how patient engagement improves the overall clinical experience and what that means for Medical Home providers

· What are the anticipated impacts - risks and rewards - of PCMH on how providers and patients interact

Seminar Speaker

Benjamin Littenberg MD, FACP

Henry and Carleen Tufo Professor of Medicine, Professor of Nursing, Director of General Internal Medicine
Division of General Internal Medicine, University of Vermont
Chief Medical Officer, Patient Engagement Systems, Inc.

Dr. Littenberg is the Henry and Carleen Tufo Professor of Medicine, Professor of Nursing and Director of General Internal Medicine at the University of Vermont. He received his medical degree from Case Western Reserve University and trained in internal medicine at Hartford Hospital in Connecticut. He was a Robert Wood Johnson Clinical Scholar at Stanford University before becoming Assistant Professor of Medicine at Dartmouth. Following an appointment as Associate Professor of Medicine at Washington University in St. Louis, he assumed his present position in 1999.

Dr. Littenberg practices General Internal Medicine in Burlington, Vermont. His research interests center on technology assessment and quality improvement. Recent projects include new ways to measure quality of care in cancer, novel strategies for reporting test results to patients, better approaches to antibiotics in sinusitis, safety improvements in outpatient prescriptions, and strategies to address health literacy.

In Vermont, Dr. Littenberg has been active on the Board of the Vermont Program for Quality in Health Care. He has developed statewide registry-based approaches to quality and safety improvement with the Vermont Breast Cancer Surveillance System and as Principal Investigator of the NIH-funded research grant for the Patient Engagement Systems Diabetes Information System which engendered Patient Engagement Systems.

Patient Engagement Systems

89 Beaumont Ave.

Given Courtyard, 4 South

Burlington, VT 05405

(802) 656-4576

About Patient Engagement Systems®

The patent-pending PES technology uses automated reminders, alerts, flow sheets and population reports to help health care providers better care for their patients, and patients better manage their chronic conditions. PES has been used by thousands of patients with diabetes in Vermont, New York, California and Texas. Clients include municipalities, private hospital systems, physician organizations, and managed care organizations. For more information about Patient Engagement Systems (PES), visit http://www.patientengagementsystems.com.

Exchanging Health Information to improve medication adherence

noreply@blogger.com (Ben Littenberg) — Sat, 10 Sep 2011 14:33:00 +0000

Getting the right medicine into the right patient at the right time is a particularly challenging problem in outpatient care. Consider the required steps:

Prescriber selects the right medication
Prescriber prescribes the right medication
Patient carries the paper prescription to the pharmacy
Pharmacist interprets the written prescription correctly
Pharmacist selects, packages and labels the medication correctly
Patient returns to pharmacy
Patient receives the correct package
Patient takes the medication as prescribed
Patient requests refill at appropriate time
Return to Step 5

There are lots of variations on this scheme depending on insurance, expired prescriptions, need for clarifications, etc, etc., etc. A big one recently is that Step #3 is sometimes replaced by a network connection with quite high reliability.

There have been a number of studies on "secondary non-adherence" in which the pharmacy records identify patients who don't get refills (Step #9). There have even been some analyses of patients who drop off their paper prescription but fail to pick up the medicines (Step #6). However, until recently, the gap between prescribing and dispensing the first unit (Steps #3, "Primary Non-adherence") has been very difficult to study because of the lack of information exchange between the prescriber and the dispenser.

Marsha A. Raebel and the good folks at the Kaiser Permanente Institute for Health Research in Colorado just published an article in The Journal of General Internal Medicine about using health technology to identify those patients who need help in getting their first fill. They looked at over 12,000 new electronic prescriptions for blood pressure, cholesterol or diabetes. Overall, about 7% failed to pick up their first medication, even though these patients had pretty good insurance coverage.

It is not clear yet why these folks don't show up to pick up their pills. Nor is it clear exactly what should be done about it. However, it is clear that this kind of health information exchange between prescribers and pharmacists should trigger an alert to someone inside the system: "This patient is not getting the intended care - call them and find out why!!"

Characteristics of Patients with Primary Non-adherence to Medications for Hypertension, Diabetes, and Lipid Disorders

Marsha A. Raebel, Jennifer L. Ellis, Nikki M. Carroll, Elizabeth A. Bayliss and Brandy McGinnis, et al.

Journal of General Internal Medicine Online First™, 30 August 2011

Empowering patients with data

noreply@blogger.com (Ben Littenberg) — Fri, 17 Jun 2011 10:38:00 +0000

I've been thinking more and more about the idea of engaging patients in their own care as the means to improve quality and reduce costs. Today I see that Farzad Mostashari, Director of the Office of the National Coordinator, is thinking along the same lines:

"The meta principle is putting patients at the center of information flows, literally. Achieving that means freeing the patient data, empowering patients by raising awareness that they can access their own data and teaching them to learn from it."

Perhaps the time has come....

Is it better to prescribe or negotiate?

noreply@blogger.com (Ben Littenberg) — Mon, 13 Jun 2011 01:58:00 +0000

Engaging patients in their own care means more than just giving them a handout or teaching them how to care for their feet. The tough part is motivating them to stay engaged for the long run. This is especially difficult when they have depression which itself induces dis-engagement from the world.

Exercise is an effective treatment for depression. It is also inexpensive and has positive benefits in other spheres of health such as weight control and heart disease prevention. However, it is notoriously difficult to get depressed patients to start exercising and to keep them engaged. One reason might be that the recommended duration and intensity of exertion can seem daunting. (30 minutes on the treadmill!!!)

A team of researchers from the University of Nottingham just published the intriguing results of a controlled trial in which they compared the effects of exercise of preferred intensity with exercise of prescribed intensity in thirty-eight women living with depression. The women who chose their own level completed more sessions and had better mental AND physical health at the end of the 12 week study.

The study is quite small (only 38 subjects) and may not be the last word on this issue, but the idea certainly warrants further investigation. It suggests that engaging patients in decisions about the dose of the treatment is effective at keeping them in the treatment. And, that's better than getting them on the "right" dose.

Pragmatic randomised controlled trial of preferred intensity exercise in women living with depression. Patrick Callaghan, Elizabeth Khalil, Ioannis Morres, Tim Carter. BMC Public Health 2011; 11:465

Smartphones for Health? A survey

noreply@blogger.com (Ben Littenberg) — Mon, 09 May 2011 22:26:00 +0000

Last month, Consumer Health Information Corporation released the results of a survey of 395 smartphone consumers. It was a good first effort to dig into a very murky, but important question: how will folks use their smartphones to manage their own health?

They reported a number of findings:

74% of smartphone apps are abandoned by the user before they use it 10 times.
Most health apps do not comply with public health guidelines.
In spite of these failings, most consumers were willing to pay a few dollars for the app.
Respondents preferred text messages over other methods of getting health reminders.

This last finding is a bit problematic. Apparently the survey included only electronic methods of communication (phone calls, e-mails, app messages, etc.). However, none of these methods has ever been shown to improve health outcomes or lower costs. On the other hand, personalized first class mail is quite effective and has been proven in large scale clinical trials to change patient behavior for the better.

I guess that's what happens when you survey cell phone users on Facebook - they tell you they like using cell phones! But whether health apps will truly change our health awaits a more rigorous evaluation, including a large randomized clinical trial.

Patient Portals and Equity

noreply@blogger.com (Ben Littenberg) — Fri, 06 May 2011 11:03:00 +0000

Mita Goel, David Baker and the good folks at Northwestern University report in the Journal of General Internal Medicine about use of the patient portal in their large, academic practice in Chicago. Of 7,088 patients invited to open an account on the portal, 69% enrolled. However, older patients and minority patients were significantly less likely to use the technology.

Once they were enrolled, race and ehtnicity didn't seem to be associated with how the patients used the portal. However, younger patients were less likely to initiate a request for refill or advice, perhaps because they have fewer medical issues. Likewise, men used the system less than women, reflecting the general tendnecy for women to seek health care more often than men.

The good news for engaging patients and exchanging health information is that over 2/3 of patients in this large, complex population took the opportunity to enroll. Patients want to connect. The bad news is that it might not help resolve the racial and ethnic divides that continue to bedevil health care and American society - it might even make them worse.

Goel M, Brown T, Williams A, Hasnain-Wynia R, Thompson J, Baker D. Disparities in Enrollment and Use of an Electronic Patient Portal. Journal of General Internal Medicine 2011; Online first at http://dx.doi.org/10.1007/s11606-011-1728-3

Sharing Information and Patient Engagement

noreply@blogger.com (Ben Littenberg) — Sat, 02 Apr 2011 14:19:00 +0000

The original motivator for electronic health records and exchanging health information (way back in the dark days of the late 20th century) was to make it easier, safer and cheaper to take care of patients. The push came largely from managers looking to reduce the transaction costs of care and providers trying to reduce the administrative overhead of care so they could spend more time dealing with patients.

However, the more I deal with health information systems, the more I see that the best and highest purpose is not for management or even professional use. Rather, it is for patients. Giving patients their own information, (in the right format, via the right medium, at the right time, and from the right source), does more than enable them to make better decisions, it engages them in their care. It motivates them, educates them, energizes them, and empowers them. Whether any specific bit of information is, by itself, critical to the patient's care is not the whole story. The mere act of sharing the information with the patient turns the patient from a passive passenger on the health care bus to the driver, choosing the destination and calling the stops.

What happens when you engage patients with chronic care by sharing their personal health information with them?
1) They like it. Really, really a lot. HIE with patients is a big satisfier.
2) It generates scheduled care, notably primary care.
3) It reduces the need for urgent and emergency care and hospitalizations.
4) It saves a huge amount of money.

(Oddly, it seems to do all this without improving the patient's disease control, their physiologic state. The mechanism for this is unclear, but more on that later.)

It's early days yet and exactly how best to share information, which information, and so forth is by no means completely clear. However, there are some very well documented examples that work and are ready for deployment now.

If you would like to learn more about this, you might want to check out a recorded webinar featuring yours truly:

Does Improving Patient Engagement Result In More Appropriate Utilization

View more videos from vermedx

I'll also be doing a presentation at the Spring Managed Care Forum in Orlando on April 15.

Does Improving Patient Engagement Result in More Appropriate Utilization

noreply@blogger.com (Ben Littenberg) — Tue, 22 Mar 2011 18:05:00 +0000

Please join me for a webinar tomorrow:

Does Improving Patient Engagement

Result in More Appropriate Utilization?

A special online seminar for senior executives, administrators, practice managers and patient outreach specialists from physician groups, emerging Accountable Care Organizations, Health Systems, Patient Centered Medical Homes, health plans, and government agencies.

To register, please click here.

Answers to Your Specific Questions

Have questions on our webinar and/or webinar formats? Please contact us at:

marketing@vermedx.com

Event Date: Thursday, March 24th

Time: 12:00 pm Eastern

The risk-reward dynamic is shifting within healthcare. Improving patient engagement is widely accepted as a critical foundation for emerging care practices, such as the patient-centered medical home.

As provider-patient interactions evolve, provider groups are realizing more and more that informed, prepared patients lead to more efficient encounters. This is especially so when managing chronic conditions.

Benjamin Littenberg, MD FACP will share from both academic and actual business cases how low cost, high touch programs can reduce avoidable health utilization and improve patient satisfaction within normal provider practice workflow.

Focused Discussion

Attendees will learn:

· What published, academic research has established about how patient engagement improves the overall clinical experience and what that means for providers?

· How large physician-lead groups have implemented technology solutions that better prepare both providers and patients for more effective clinical encounters, and how they measure it?

· What are the anticipated impacts - risks and rewards - of pay for performance and health care reform on how providers and patients interact?

To register, please click here.

Seminar Speaker

Benjamin Littenberg MD, FACP

Henry and Carleen Tufo Professor of Medicine, Professor of Nursing, Director of General Internal Medicine

Division of General Internal Medicine, University of Vermont

Chief Medical Officer, Vermedx, Inc.

Dr. Littenberg is the Henry and Carleen Tufo Professor of Medicine, Professor of Nursing and Director of General Internal Medicine at the University of Vermont. He received his medical degree from CaseWestern Reserve University and trained in internal medicine at Hartford Hospital in Connecticut. He was a Robert Wood Johnson Clinical Scholar at Stanford University before becoming Assistant Professor of Medicine at Dartmouth. Following an appointment as Associate Professor of Medicine at Washington University in St. Louis, he assumed his present position in 1999.

In Vermont, Dr. Littenberg has been active on the Board of the Vermont Program for Quality in Health Care. He has developed statewide registry-based approaches to quality and safety improvement with the Vermont Breast Cancer Surveillance System and as Principal Investigator of the NIH-funded research grant for the Vermont Diabetes Information System which engendered Vermedx.

This event is sponsored and produced by Vermedx, Inc.

89 Beaumont Ave.

Given Courtyard, 4 South

Burlington, VT 05405

(802) 656-4576

www.vermedx.com

About Vermedx®

Vermedx® technology enhances patient engagement by fostering communication between patient and caregiver, and by delivering decision support to health-care providers. The Vermedx system has been proven in a National Institute of Health clinical trial to improve health outcomes and reduce costs.

The patent-pending Vermedx technology uses automated blood test reports and notification letters to help providers better care for their patients, and patients better manage their chronic conditions. Vermedx has been used by thousands of patients with diabetes in Vermont, New York, California and Texas. Clients include municipalities, private hospital systems, physician organizations, and managed care organizations. Visitwww.vermedx.com for more information.

Are we persuasive enough?

noreply@blogger.com (Ben Littenberg) — Wed, 23 Feb 2011 14:01:00 +0000

Joseph Kvedar, M.D. at the Center for Connected Health wrote recently about embedding the basic tools of persuasion into automated interchanges for better health. Messages that take advantage of reciprocation, consistency with personal commitments, expert authority, access to scarce resources, liking the source, and social norming are more likely to be persuasive. Marketers and sales people have long known this. I also agree with him that increased demand for health care as will require some sort of efficiency gains to maintain any semblance of access and equity.

In fact, the gains had by engaging patients in their own care, combined with the efficiencies of automation, are the "secret sauce" behind the success of the Vermedx Diabetes Information System in reducing the need for hospital and Emergency Room care as well as in reducing total costs of care.

His column got me thinking about our own automated messages within the Vermedx system. The letters to patients clearly take advantage of personal commitments and expert authority, but they could make better use of social norming and access to scarce resources. However, we take advantage or another technique that wasn't mentioned: specificity. Vermedx messages include information that is timely, specific, and actionable. Rather than say "You ought to get blood tests regularly," Vermedx tells the patient exactly when the test was due and what to do about it now.

We're going to be working on better ways to incorporate all the positive aspects of the Psychology of Persuasion (or Behavioral Economics, if you prefer) to make even greater gains in health outcomes.

How big a chunk of information do we want to exchange?

noreply@blogger.com (Ben Littenberg) — Mon, 14 Feb 2011 12:02:00 +0000

John Halamka and Wes Rishel have a very interesting approach to the recent debates on just what it is we might be exchanging in Health Information Exchanges. The problem arises from a tension among the need to care for the individual patient in front of you right now, to put that patient's care in the context of their history over time, and to take a broader view of a population of patients.

The provider with an individual case in the here and now traditionally generates a progress note - a document with whatever he or she thinks is required for the purposes of care. Much of professional education is transmitting the law and lore of what must/may/mustn't go into these documents and how to organize them for their various audiences. In general, they are free text, minimally organized with perhaps a few headings (Chief Complaint, Past Medical History, Assessment, etc.) and highly variable both across and within practitioners. (Some ten years ago, when Medicare mandated the presence of a Review of Systems for most office and hospital visits, the push-back from providers was huge and some actually left the profession rather than comply with this minimal nod towards standardization.)

Caring for patients in context requires the assembly of data across time and space and is the first place that electronic health records really shine. Knowing that the patient has an abnormal cardiogram now is valuable. Knowing that it is unchanged from one taken a year ago by another physician is gold. Sharing documents across settings and providers accomplishes much of this, although it can certainly be improved upon with a little more granular organization.

At the population level, however, unstructured documents are not all that useful. Searching for the incidence of diabetic foot examination in our institution required natural language processing of many thousands of documents and failed to produce a reliable estimate [Kost, Chen, Littenberg et al. AMIA 2009]. Rather, we need standardized components of documents that can be extracted, transmitted, understood both as stand-alone entities and in the context they arose from, and analyzed for population as well as individual purposes.

Clinical laboratory data have long had these characteristics. A more-or-less complete documentation of a clinical chemistry test will consist of patient identifiers, specimen source (blood, urine, etc.), date and time of acquisition, analytic method, result, and units. However, even these simple concepts are represented by a bewildering array of formats and definitions. To make matters worse, clinical labs routinely change their analytic methods, units, test names and any of these details, sometimes without even warning the users! A huge amount of effort goes into maintaining the clinical laboratory interfaces at Vermedx to ensure that these data continue to be useful over time.

More complex and less structured data such as pathology reports, operative notes, and discharge summaries are going to require a very large amount of work to make them transmissible and useful at this level. The first steps seem to be to agree upon what the smaller, irreducible units of information should be. This will undoubtedly be the battlefield of yet another IS standards war, but the outcome will have very big implications for how, and even whether, we can exchange health information into the future.

Consumer Health Information Quality

noreply@blogger.com (Ben Littenberg) — Wed, 29 Dec 2010 13:18:00 +0000

We usually write about the exchange of individual patient's information here at HealthInfoEx, but a recent article by R. Scott Braithwaite at New York University Medical Center, published in the Journal of General Internal Medicine, brings up a very fine idea about the quality of consumer health information. To help stem the tide of over-hyped scientific trivia passed off as "breakthrough in health care," Braithwaite suggests that medical journals include a consumer rating scale. He very reasonably suggests using the US Preventive Services Task Force quality of evidence scale as a template and has a number of clever ideas to encourage lay media outlets to use it.

Braithwaite is worried about blogs (which he refers to, with a bit of a sniff, as "gray literature") and fears they wouldn't play along. Perhaps the blog certification services, like the Health on the Net Foundation, should require it to earn their seal of approval. (HON puts HealthInfoEx through the wringer on a regular basis.)

Kudos to Scott Braithwaite for a good idea on a vexing problem!

Clinical, Technical and Policy Issues in Exchanging Health Information

noreply@blogger.com (Ben Littenberg) — Wed, 17 Nov 2010 01:06:00 +0000

Every once in a while we get a request by a reader to post a guest entry on the blog. Frankly, we remain a bit dubious. But they are so eager, we allow the better angels of our otherwise controlling nature some free rein. So, here is a guest post for your interest and enjoyment. Many thanks to author Rachel Davis who more often writes on Radiology degrees . She welcomes your comments at racheldavis65[@]gmail[.]com.

Clinical, Technical and Policy Issues in Exchanging Health Information

Health Information Exchange (HIE) has been proposed as one of the best ways to reduce waste and bring down costs in the healthcare system – when patient information is shared electronically across disparate healthcare systems without compromising on security, meaning and accuracy, it enables optimal provision of health care. For HIE to achieve success and attain its goals, the clinical, technical and policy issues relevant to the exchange of health information must be defined clearly and followed accurately.

Clinical issues are those that relate directly to patient care and which facilitate the provision of effective care in the shortest possible time and at the least possible cost. A study conducted by the Medical College of Wisconsin has found that ER doctors who have electronic access to patient data through a HIE spend less time in gathering information and make clinical decisions that are better informed and lead to better care for the patient. Clinical issues of a HIE deal with the accurate collection and compilation of information such as lab procedures, prescribed medication, patients’ main complaints, prior visits and treatments, and any other data that helps the attending doctor gain a more comprehensive picture of the medical history of the patient. When clinical information is accurate, it prevents errors, reduces wastage of time, effort, and money, and eliminates redundancy – time and money are not wasted on tests that have already been done, and medicines that cause allergies and adverse reactions are not prescribed inadvertently.

The technical issues relate to the software and hardware requirements for the implementation of the HIE. The underlying architecture of the HIE must be designed and implemented, and it should include information relating to medication history standards, laboratory result standards, issues that relate to data quality, and the implementation of a record locator service.

Policy issues relate to the privacy aspects in a networked HIE, privacy policies and procedures that relate to a HIE, notification and consent when using a record locator service, matching patients to their records correctly and without any mix-ups, authenticating and setting levels of access for users, deciding on patient access to their own information (and protecting information of other patients), auditing access to a HIE, breaches of confidential health information, and a common and standardized framework for networked personal health information.

A Health Information Exchange must resolve clinical, technical and policy issues before it can be implemented successfully in any healthcare setting.

The Little Blue Button

noreply@blogger.com (Ben Littenberg) — Wed, 01 Sep 2010 14:00:00 +0000

The Markle Foundation is promoting easier access to health information for patients. They propose that systems that contain personal health information have "a little blue button" that allows the patient to download all their own data. What are the upsides? This Markle Policy Brief suggests that it would::

• Change consumer expectations and help them become more efficient in managing
their health information.
• Increase market pressure for technical standards to exchange electronic health data.
• Enable innovation through a host of applications and services that could add
significant value to individuals by using their information with their permission, such
as tools to help people with diabetes track their blood sugar, medication use, and
preventive care.

We're all for that! How about downsides? Well, privacy certainly seems an issue. Can we be sure that others aren't downloading our embarrassing details? The technology is available for encryption, passwording, and the like. The biggest threats will be the usual "social hacks" like phishing, password guessing, and just conning folks out of their passwords.

What about erroneous information? We certainly don't want to be telling patients stuff about their health status that isn't true. Thinking that you have a nasty health problem because of an erroneous billing entry can cause some pretty sleepless nights. So, we need real clarity on what is valid personal health information (such as a confirmed diagnosis) and what is merely a weak proxy (a single test result, a billing code, a possibility mentioned in a differential diagnosis list, etc.). However, the best strategy for errors in the data stream is to have someone who cares check it out. Giving patients an easy way to review their medical record and give corrective feedback ("I had heartburn, not a heart attack.") would be a great leap forward.

It looks like the VA may be among the first systems to offer a blue button. They have announced that it is available to users of their MyHealthVet portal. However, the sample report they show seems awfully long on patient-entered data and awfully short on the diagnoses, lab results, procedures, problems lists, and progress notes that make up the VA's medical records.

So, there is a lot of good in the idea of the "Little Blue Button" (beyond the wonderful pirating of a ubiquitous pharmaceutical marketing campaign), but, as always, the devil will be in the details.

noreply@blogger.com (Ben Littenberg) — Wed, 25 Aug 2010 00:31:00 +0000

The CDC runs one of the great health information resources for those of us trying to figure out how to keep folks health: The Behavioral Risk Factor Surveillance System. It uses phone interviews of randomly selected people from all over the US to make estimates of various health problems. They recently released new data, including the prevalence of diabetes by metropolitan area. For those of you keeping score, the winners and losers are:

Highest prevalence of diabetes:

Kingsport-Bristol, TN-VA 15.4%

Huntington-Ashland, WV-KY-OH 14.7%

Shreveport-Bossier City, LA 13.4%

Charleston, WV 13.1%

Chattanooga, TN-GA 13.1%

Lowest prevalence of diabetes: Bozeman, MT 2.8%

Fort Collins-Loveland, CO 4.2%

Fargo, ND-MN 4.4%

Provo-Orem, UT 4.7%

Heber, UT 4.8%

(My home town of Burlington, VT, where we developed the Vermedx Diabetes Information System, came in 6th at 5.1%. We're sore losers and we won't rest till we're the best!)

Here is map showing the whole nation:

These kind of data can tell us a lot about where we need to go to have the biggest impact on people's lives.

Crowd Sourcing for Maternal Health

noreply@blogger.com (Ben Littenberg) — Sat, 31 Jul 2010 22:16:00 +0000

The high rate of devastating complications of pregnancy, labor and delivery continues to be a desperate problem, especially in poorer parts of the world. The good folks at Oxford University are trying a new approach to understanding the barriers to better maternal health and perhaps to finding answers: they're asking folks. Which folks? Just about everybody who takes care of expectant mothers in third world settings. They've set up a web site, Global Voices for Maternal Health, to use crowd-sourcing to get more and better input into this problem. (Even if you're not a third world maternal health provider, you're welcome to participate in the discussions.)

Crowdsourcing is the use of large numbers of distributed workers (usually interacting over the Internet) to solve problems or do tasks that are difficult for smaller teams to do. It has been used in the arts, business (especially marketing), and in science, but hasn't had much application in health that I know of. (Innocentive has applied it to biomedical science, but not to health care delivery.) So, this project is a bit of first.

Will they get the magic bullet answer that has eluded all the experts and policy makers for decades? Probably not. But they might get more than a few really great ideas that can have a positive impact on the lives of millions. It's a clever way to take advantage of new technologies to generate more and better information and certianly worth a try.

The Next Great Healthcare Revolution?

noreply@blogger.com (Ben Littenberg) — Wed, 21 Jul 2010 00:04:00 +0000

Your hosts here at HIE are happy to share the bully pulpit on occasion with folks who want to put their 2 cents in about moving information around to make care better. So, here is piece by guest blogger Alexis Bonari.

Health Information Systems: The Next Great Healthcare Revolution

As online database technology moves to the forefront in many industries, we are faced with a crucial question: would a Health Information System create an environment that fostered a higher standard of patient care? It would certainly make the transfer of records from one doctor or healthcare provider to another much simpler than it currently is.

How it would work.
A comprehensive Health Information System would encompass all of the patient’s medical records. Often, a patient might forget to report a treatment they had undergone years in the past. When seeking treatment for a more current problem, the doctor overseeing the case might benefit from knowing about the previous procedure or diagnosis.

Prevention is key.
Further, the past case history might be used to develop a preventative care plan for given potential illnesses. Let’s say, for example, that a patient had suffered from an eating disorder during their adolescence. That person would be more likely to experience the effects of weakened bones and teeth later in their adult life. A few simple preventative measures would potentially prevent them from losing teeth due to calcium deficiency or from allowing osteoporosis to gain a foothold. Without access to their adolescent medical records, a doctor wouldn’t have the information necessary to create such a plan.

The power of statistics.
Over the long term, a Health Information System would allow the medical community to track the health of the nation, individuals, families, and certain demographics. No longer would we have to rely upon statistical sampling techniques to determine the exact incidence of cancer in a given population. We would already have the data available. Currently, data used to determine such statistics is expensive and difficult to gather.

Family ties.
Further, families could identify disease trends over multiple generations. As more is understood about the genetic component of certain types of cancers, etc. a statistical model could be produced for each individual that would predict the likelihood that they would develop particular diseases or conditions. Once again, preventative care could be tailored to the specific needs of the individual.

Privacy issues.
The primary concern when creating a Health Information System would be the problem of patient privacy.   If steps weren’t taken to prevent it, financially interested individuals and organizations, such as health insurance companies and any government health organization, might use the information obtained as justification to withhold or limit treatment from currently healthy individuals. This problem would have to be foreseen and prevented from the inception of the Health Information System. Ideally, the system should only be used for improving patient care and for disease prevention.

Alexis Bonari is a freelance writer and blog junkie. She is currently a resident blogger at First in Education, researching various accredited online degree programs. In her spare time, she enjoys square-foot gardening, swimming, and avoiding her laptop.