The Mobile Phone Seems To Be Making A Difference. Diabetes Care Assisted By Your Phone!

The following very interesting article appeared a week or so ago.

AUGUST 2, 2011

Ring! Time for Blood Test

By JENNIFER CORBETT DOOREN

Software added to basic cellphones helped people with diabetes significantly reduce a key measure of blood sugar over a year, according to one of the largest clinical studies of medical uses for mobile-phone technology.

The software is designed to be a virtual coach to help patients manage their disease. It instructs them how to address daily blood-sugar readings and asks whether they've exercised. It also lets doctors and nurses access the information through a secure website to help make treatment decisions.

"Mobile health has the potential to help patients better self-manage any chronic disease, not just diabetes," said Charlene Quinn, the study's lead researcher and an assistant professor of epidemiology and public health at the University of Maryland School of Medicine.

Mobile medical technology is a rapidly growing field. The Food and Drug Administration last month outlined how it planned to regulate it by focusing on mobile applications that could present a risk to patients if they don't work as intended. The technology used in the diabetes study was developed by WellDoc, a Baltimore-based firm and was cleared for use last year by the FDA. Sanofi-Aventis has developed a mobile diabetes management system under FDA review. Other companies including Medtronic Inc. and Johnson & Johnson's LifeScan unit are also developing mobile diabetes-management systems.

The study, which involved people with Type 2 diabetes, was released online and will be in the September edition of Diabetes Care, a medical journal published by the American Diabetes Association.

.....

Patients with the cellphones would enter blood glucose readings and would receive a text message back in cases when the reading was considered too high or low. If a reading was high, the system might ask if medication was taken. In the case of a low reading, a patient was told to eat and then retest blood sugar levels. The phone could be set to send a retest reminder.

The main study goal was to compare changes in hemoglobin A1C, which is a measure of long-term blood sugar control. The American Diabetes Association recommends that a person's A1C be less than 7%. Most Americans with Type 2 diabetes have an average level of more than 9%, which greatly increases their risk of complications that include heart, kidney and eye problems that can lead to blindness.

The full article is here:

http://online.wsj.com/article/SB10001424053111903341404576482383432907992.html

This really is a very nice attempt at assisting an individual take charge of their own care - assisted by pretty cheap and easily accessible technology.

I especially liked the automatic follow-up after an intervention.

David.

Interesting Issues Around Connecting iPads to EHR Systems - Especially Older Ones.

This popped up a little while ago.

Experts debate merits of virtualized vs native iPad EHR implementation

CAMBRIDGE, Mass. -- Among physicians and nurses, iPad adoption is expanding at a much faster rate than in the general consumer population -- and they want their electronic health records system to run on it, said speakers on a panel at the World Congress 3rd Annual Leadership Summit on mHealth. That leaves CIOs with a dilemma when it comes to hospital iPad EHR implementation: Run a native app or a desktop virtualized to the iPad?

Both have their tradeoffs. Virtualized environments offer unparalleled security -- and by extension, HIPAA compliance -- at the expense of speed and features tailored to the iPad and iOS operating system's touch screen.

Native iPad EHR systems, on the other hand, dovetail better with the iPad's design, with scrolling, page-turning and other features iPad diehards swear boost their productivity. However, these apps can also pose risks when an iPad is lost or stolen and therefore require more security safeguards. Native apps also may require in-house development or customization resources that many hospitals cannot afford.

Overall, if you can get employee buy-in for an iPad EHR implementation, said Dale Potter, senior vice president and CIO at Ottawa Hospital, it is quite economical. "These devices are six hundred bucks," Potter said. "Some medical equipment these physicians carry around -- [such as] a stethoscope -- can cost you much more than that."

Virtualization in Indiana EHR implementation

Before the "virtualization or native" decision can be made, Deaconess Health System CIO Todd Richardson said, a hospital has to decide if it will purchase iPads or let employees bring in their personal devices to use on the network. He took the latter approach for the six hospitals in his system, which serves western Kentucky, southern Indiana and southeastern Illinois.

His organization adopted the view that tablets, like cell phones, are a personal investment -- everyone who truly wants one already has one. Not only does that kind of thinking eliminate the capital outlay and need to track iPads throughout the enterprise. It also saves IT staff from policing devices for personal data and apps such as contacts and music. Furthermore, the policy prevents the "arms race" between physicians lobbying IT staff for upgrades when faster, larger-capacity iPads come to market -- users either upgrade themselves or they don't.

"As a CIO, it makes me sleep easier at night knowing it's a pain...I don't have to deal with, quite frankly," Richardson said. "And they're going to take better care of it."

That said, there's no one right way and one wrong way to do an iPad EHR implementation, said Richardson, who chose to use Citrix Systems Inc. to virtualize the hospital's existing Epic Systems Inc. EHR system. "Different health care systems have different cultures, and different ways of doing things. What works in one spot clearly does not work from Santa Fe to Evansville to Waterloo, Iowa."

With the virtualized EHR implementation, no patient data is stored on the iPads. This greatly simplifies HIPAA compliance. Richardson said the difficult challenge in getting the system to work was creating wireless connectivity throughout their facilities, which include lead-lined buildings that required creative positioning of access points so physicians would not drop off the network. It became especially thorny in difficult spaces such as stairwells. After that came the issues of securing the wireless network and giving physicians priority bandwidth.

While the transition has not been seamless, Richardson said physician affinity to the iPad is so great that they will take on the learning curve.

"We had the experience of a neurosurgeon calling and screaming because he couldn't connect from Owensboro [Ky.] on his iPad to check orders and things," he said, sheepishly. "When you've got a neurosurgeon screaming at you that [he] can't connect through [his] iPad, you've won the war -- and now the battle is figuring out why it's not connected."

Heaps more here:

http://searchhealthit.techtarget.com/news/2240039365/Experts-debate-merits-of-virtualized-vs-native-iPad-EHR-implementation

There is a lot in this article that is worth thinking about.

The first and most obvious is that it seems there is genuine clinician enthusiasm to adopt user interfaces that are as intuitive and work as well as the Apple iOS interface.

The second is that there are some real issues trying to preserve both security and interactivity when an interface of this underlying complexity is being asked to interact with systems which were designed long before Android and iOS were a twinkle in anyone’s eye.

Third it is clear that Hospital IT and Support Departments have a considerable learning curve to scale with all this.

Last it seems the Health IT provider community really have some work ahead to provide attractive user experiences that will be satisfactory to the iPhone and iPad users!

Amazing stuff.

David.

The Consent Model For the PCEHR Needs To Be Sorted Out Correctly. We See Some Odd Allies on A Different View.

The Government really has a difficult to choice to make with the consent model to be applied to the PCEHR.

In the last few weeks we have had a number of contributions to this debate.

First (most recently) here:

Guild backs AMA call for e-health rethink

• By Nick O'Donoghue on 8 August 2011

Plans to introduce an opt-in, personally controlled health record system in Australia next year are doomed to failure, according to the Australian Medical Association (AMA).

Dr Steve Hambleton, AMA national president, said the Federal Government should make the system opt-out to maximize uptake, otherwise her feared elderly patients and those who are not technically savvy may miss out.

In Auckland just 91 of one million people opted out of a similar electronic health record when it was introduced there, Dr Hambleton told Sydney’s Sun Herald newspaper.

Tim Logan, acting national president of the Pharmacy Guild of Australia supported the AMA’s position and described the opt-out proposal as the “more sensible option”.

“The PCEHR has the potential to be a technological breakthrough in health management, but it’s so easy to get this wrong,” he said.

Dr Hambleton’s comments echo claims by Kos Sclavos, Guild national president, who said the opt-in system offered no incentive for patients to sign up to the electronic health, earlier this year.

More here:

http://www.pharmacynews.com.au/news/guild-backs-ama-call-for-e-health-rethink

Here is the older report covering the AMA view.

Online health records face uphill battle

Jim O'Rourke

August 7, 2011

A NEW online medical records system is doomed to failure because not enough people will sign up for it, the Australian Medical Association has warned.

From July 1 next year, patients will have to volunteer to ''opt in'' to the system, which stores all their health details, including test results and prescriptions, in a national database. It's the first time patients will be able to access their medical information.

The AMA believes inclusion in the federal government's Personally Controlled Electronic Health Record system should be automatic unless patients choose to ''opt out''. Otherwise, many patients in nursing homes, the elderly or others who are not ''technically savvy'' will miss out, the group's national president, Steve Hambleton, said.

Mr Hambleton said the medical profession supported the concept of having a one-stop source of medical information ''but people should be asked if they want to leave the scheme, not if they want to join''.

''When they did this in Auckland, where they had a million people, only 91 people opted out,'' he said.

John Bennett, chair of the e-health national standing committee at the Royal Australian College of General Practice, said the opt-in issue would be challenging.

''Unless you get enough people taking part in the system, that's healthcare providers and the community, it's hard to have enough information available to make it useful,'' he said.

http://www.smh.com.au/national/online-health-records-face-uphill-battle-20110806-1igfk.html

Also we have had a piece of commentary from Accenture who have experience with a number of health systems all over the world.

EHR Systems—Opt In or Opt Out?

It’s a Question of Information Governance

The short position paper is found here:

http://www.accenture.com/SiteCollectionDocuments/PDF/Accenture_Health_OptInOptOut.pdf

The bottom line from all this seems to me to be that if you want rapid adoption and use of whatever comes from the PCEHR program then opt-out makes some sense. However, unless there can be a high degree of confidence that there will be a level of ‘information governance’ will be adequate to virtually guarantee personal information security and privacy, such a position is really difficult to support.

We have some reassurance from the success of Medicare Australia in protecting their personal information, however their record is not totally unblemished. See here for a link to that material.

http://aushealthit.blogspot.com/2010/03/confirmation-that-medicare-australia.html

There seems to be no doubt that if opt-in is chosen that adoption will indeed be very slow indeed.

At the very least, before opt-out is considered, there does need to be the proper infrastructure, including NASH, in place and the education of users of all sorts needs to be fully implemented and delivered.

From the Government's perspective this really is a 'wicked problem'. Go opt-in and really risk a white elephant or go opt-out and wind up in a political bun-fight.

Views on this issue are more than welcome!

David.

E-Health Dissent Arrives At Crikey. Good To See Something Other Than Unalloyed Enthusiasm Get a Run!

The following popped up today.

Thursday, 18 August 2011 /

Roxon’s health records system a ‘massive waste of $467 million’

by Andrew Crook

The headline announcement this week that health minister Nicola Roxon had hatched a $77 million deal with global services behemoth Accenture to deliver its controversial e-health records system has failed to quell the rage of vocal detractors who say taxpayers are being taken for a ride.

The chosen consortium, also including Oracle, Orion Health and a suite of smaller IT minnows, is charged with rolling out the $467 million “personally controlled electronic healthcare record system”, or PCEHR. It will allow patients to register for an e-health record that could be accessed by GPs and specialists around the country. The winning trio triumphed in the Singapore government’s bid to deliver a similar system last year.

Roxon has unsurprisingly championed the project, due to go live next July, with a spokesperson telling Crikey this morning that it represents “good value for money and will pay dividends for Australian patients for many years to come”. But a range of critics, led by the Australian Privacy Foundation and the Australian Medical Association, continue to arc up.

Prominent e-health dissenter Dr David More, a former acting-chief information officer in NSW (Health), questioned the raison d’etre of the entire initiative.

“You’ve got to step back and ask yourself is this a sensible thing to be doing and is this the right approach? Only then can you begin to start measuring whether it’s value for money … this is one of these utterly crap projects that is ill-considered, it’s not being managed well and it’s going to fall over big time. It’s a massive waste of $467 million.”

Dr More said that government has conceived the project simply to “tick the box” on e-health without looking at what the project’s broader aims and goals were meant to be.

“There’s one huge question you have to ask. Who is this EHR for? Is it for doctors to communicate with other doctors and share patients’ information so that the quality of care improves or is it for patients to record what they think? The two things are not the same system.”

There is lots of other dissenters gathered here as well! See

http://www.crikey.com.au/2011/08/18/roxons-health-records-system-a-massive-waste-of-467-million/

It will be fun to see what comments get posted!

Enjoy!

David.

What Is The Problem With E-Health - Could It Just Be Complexity or Is It Something Else?

There have been some interesting discussions in the last little while asking ‘what is wrong with e-health’ or ‘why are we not having more success with e-Health implementation’?

Some commentary is here:

Studies point to complexity of HIT transition

August 10, 2011 | Jeff Rowe, HITECH Watch

Like it or not, spending the public’s money on the HIT transition is a Catch-22.

On the one hand, billions of dollars are being spent on a promise. On the other hand, there’s no way of knowing for sure whether the promise will come true until those billions are spent.

There are, of course, many reasons to believe we’re heading in the right direction, but skepticism remains, and skeptics seem to be getting a little help from researchers.

According to this article, “more and more studies are questioning the efficacy of electronic health records, and the U.S. Food and Drug Administration has begun collecting reports involving electronic health and IT errors, some of which have resulted in death.”

More here:

http://www.healthcareitnews.com/blog/studies-point-complexity-hit-transition

Here is the article that was being discussed.

Electronic records no panacea for health care industry

Studies show errors, inefficiencies still occur in medical services

Sunday, August 07, 2011

By Bill Toland, Pittsburgh Post-Gazette

It has become health care industry dogma that electronic records can help improve efficiency. Reduce errors. Save lives. And -- just maybe -- put the brakes on runaway health costs, by allowing better sharing of patient information and eliminating duplicative services.

It's why hospitals and physicians' practices across the country want a piece of the $27 billion in federal stimulus incentive money to help doctors move their systems away from papers and manila file folders and toward computerization.

It's why Highmark and West Penn Allegheny Health System recently announced a partnership with Allscripts and Accenture to provide Pittsburgh's independent physicians with electronic health records.

And it's why, starting in 2015, hospitals and doctors face cuts to their Medicare and Medicaid reimbursements if they haven't adopted "meaningful" health information technology hardware, electronic prescribing systems and other elements of President Barack Obama's Health Information Technology for Economic and Clinical Health act, known as HITECH.

Moving to a fully electronic system, Mr. Obama told Congress in February 2009 -- citing a 2005 Rand Corp. study -- could net $80 billion annual savings for the health system.

But do electronic records systems fully deliver on their promise? It's not uncommon for doctors, especially those from smaller practices, to complain about the computerization process itself -- it takes time and money to overhaul operations. Change is often unwelcome.

But it's also becoming more common to question whether the measures themselves will meet their lofty expectations. More and more studies are questioning the efficacy of electronic health records, and the U.S. Food and Drug Administration has begun collecting reports involving electronic health and IT errors, some of which have resulted in death.

"I don't think that we are getting our money's worth from all this treasury that we are spending," said Jaan Sidorov, Harrisburg-based health care consultant.

"The thing about these systems is that it doesn't really look like they're getting any cheaper," he said. "And the upgrades and the upkeep represents a very significant cost, especially in outpatient clinics."

Most clinics and hospital systems will say the return on investment for big IT projects is minimal in the short and medium terms.

And in some ways they can contribute cost to the medical system -- some software systems, for example, have auditing components that allow practices to uncover billable services that the practice had been missing.

In other words, the "efficiencies" that are realized may benefit the provider but not necessarily the insurer.

But that's just the cost side -- what about quality of care?

The hope is that computerized decision support systems will warn a physician if a drug dosage is too high or too low; digital health records can be transmitted more quickly among practices and specialists; computers can use logarithms to flag patients who are at risk for high-cost conditions.

The proposed benefits are tantalizing.

But lots of experts say we're just not there yet.

Overwhelming complexity

"Health information technology can meet the goals that are talked about," said Scot M. Silverstein, a medical IT expert and adjunct professor at Drexel University, College of Information Science and Technology, in Philadelphia. "But only if done well. And the amount of complexity behind that simple phrase -- 'if done well' -- is enormous and largely unrecognized and ignored."

The Journal of the American Medical Informatics Association published a report this summer suggesting electronic health records aren't as error-proof as advertised.

Having analyzed 3,850 computer-generated prescriptions received by a commercial outpatient pharmacy chain, a clinical panel found that 452 of the prescriptions, or about 12 percent, contained errors. (A "computerized" prescription is one that is typed into a computer, rather than a note pad; an "electronic" prescription is one that has been transmitted by email or wireless to a pharmacy.)

Of those, 163 contained mistakes that could have led to "adverse drug events." Most errors were mistakes of omission -- a doctor left out an important piece of data.

Notably, this "is consistent with the literature on manual handwritten prescription error rates," the report said. Also, the number and severity of errors varied by the type of computerized prescribing system, which suggests that some systems may be better designed than others.

Lots more here:

http://www.post-gazette.com/pg/11219/1165767-114-0.stm?cmpid=nationworld.xml

Some local contributors have also had a recent say on the matter.

What makes Healthcare different?

Posted on August 10, 2011 by Grahame Grieve

Tom Beale has picked up on a thread about what makes healthcare different (and kindly cited my earlier post on the subject).

I’m going to pick up on something Tom says, because it’s very much in my mind at the moment:

why can’t the health sector get its act together with ICT?

The implication here is that some other sectors have. Apparently.

Well, I’d like to know what ones have? When I look at the other industries, I see a pattern:

• Businesses develop new services (sometimes based on new technologies)
• As the use of the service coalesces, the variability of the service becomes a tax, not a benefit
• A bunch of industry big wigs decide to make it a commodity instead (sometimes external prompt from government is needed)
• They create a consortium, gather a bunch of engineers, come up with a partially/mostly bespoke solution, and call it a standard
• Then they pass it over to the operational guys who run it to the ground with adoption and conformance etc

A bunch of piecemeal standards. What is healthcare supposed to learn from this?

More here:

http://www.healthintersections.com.au/?p=465

We also have a recent contribution from Tom Beale.

Why e-health really is hard

Every so often, someone asks: why can’t the health sector get its act together with ICT? Tell me why health is ‘different’?

Every so often a new and interesting answer to this question pops up…John Halamka just published an excellent list of 7 things that make healthcare (and by extension, health-related computing) hard in this post. Given his day job, this list can be taken as something very close to reality rather than being purely speculative. I mentioned a few of these things peripherally in an old blog post on the e-health standards crisis. Halamka’s comments just make me think that the The Innovator’s Prescription (Clayton M Christensen, Jerome H Grossman, Jason Hwang) really does provide an excellent analysis on how to think about economics and health care.

For a bit of history on the economic analysis of healthcare, including the amoral view on health of right-wing US commentator Rush Limbaugh, see here.

For a philosophical point of view, see these posts by Colin Farrelly (Professor and Queen’s National Scholar in the Dept of Political Studies at Queen’s University) – part 1, part 2.

Grahame Grieve recently put up his list of why healthcare is special, which touches on computing, sociology and economics.

In 2005 I wrote a paper for IMIA called ‘Why is the EHR so hard‘, in which I took a biomedical/social complexity viewpoint (more or less ignoring Halamka’s points above), and used EHR requirements as a way of looking at health complexity:

• information and efficient user interface reflecting multiple levels of hierarchical biological and social organisation;
• mobile patients;
• longevity of information (e.g. 100 years);
• multi-lingual;
• data shared and authored by multiple users simultaneously;
• integrated with knowledge bases such as terminology and clinical guidelines;
• wide geographical availability of a given record to multiple carers and applications;
• consent-based, potentially finegrained privacy rules on information use (with exceptions for emergency access);
• multiple sources of constant change to requirements including medical technology, clinical procedures and guidelines, genomic/proteomic medicine;
• reliable medico-legal support for all users.

More from Tom Beale here:

http://wolandscat.net/2011/08/10/why-e-health-really-is-hard/

The original post from Grahame Grieve is here:

Healthcare is Special

Posted on May 21, 2011 by Grahame Grieve

Healthcare is special. Things that work in other industries won’t work in healthcare.

If I had a dollar for every time I’ve heard that… well, I could be sitting off a beach somewhere, surfing. Though usually, this statement is immediately followed by its denial, that healthcare is not actually special, that every industry thinks it’s special (and, if every other industry thinks it’s special, doesn’t that make healthcare special all by itself?). But for every person who says that, who wishes to claim it’s not true, there’s ten people who, whether they believe it or not, act like it’s true, behave as if its truth is one of the founding principles of their lives.

But is healthcare so special? In fact, just what is healthcare?

There is a wide scope of IT systems and/or applications that may be included under the banner of “Healthcare”:

• Patient Administration systems
• Clinical Tracking and Reporting software
• Clinical Decision Support Systems
• Financial transactions for payments related to healthcare
• Population statistics and forecasting software
• Specialized variants of standard IT infrastructure
• Patient-centric healthcare data tracking software
• Bioanalytical programs or frameworks, both in research and in diagnostics

Within this wide scope, several different factors combine to make healthcare different, and potentially special.

More here:

http://www.healthintersections.com.au/?p=279

Note: to get the full flavour of this all the links really need to be followed and each read in full.

Having read all this I am stimulated to have my two cents worth.

For me the issue is one of how we represent clinical information in electronic form and how that actually relates to how clinicians think about clinical information in the processes of delivering care.

I recognise all that the various writers are saying, and there is much truth there. What I think is missing is what I would term the ‘subtlety’ and non-binary way in which clinical information is gathered and processed by a clinician in the process for formulating a diagnosis and then deciding on treatment.

Underpinning most EHRs there is a data and ultimately information model and, like all models, this can only represent one version of ‘truth’ and like all models is only able to handle a part of reality. As they say no model is complete but some are useful. When it comes to modelling an individual expression of illness residing in an individual patient the complexity is really quite daunting.

Most diagnosis and diagnoses are not utterly clear cut and each diagnosis will usually have - in the clinician’s mind - a degree of uncertainty associated with it. This uncertainty is typically not documented well with a diagnosis being described in words which provide only a limited degree of shades of grey. (Probable, Possible, Highly Likely or Unlikely being the most common). Many physicians also have a final section in their letter headed ‘Impression’ which tries to capture the level of uncertainty.

Similarly extra complexity and difficulty arises when you start to realise that most of the patients we think can be most helped by a clinical record have multiple, interacting illnesses which lead to all sorts of issues as treatment is planned.

As I said to one correspondent “Tell me how we can handle a specialist letter - subtle, complex, unique to the patient and reflecting insights from patient and doctor?” Inevitably there is more that could be said, some things are maybe highlighted while others are de-emphasised - on the conscious decision of a clinician trying to communicate what they see as important. Coding and processing this subtle maybe subtext information is really just not possible as far as I can tell.

With SNOMED seemingly having issues, HL7 V3.0 requiring a ‘fresh look’ after 18 years and the complexity issues I have raised above I really think the strategy should be to approach record sharing (where the clinicians don’t know each other etc.) as sharing of the absolute basics - until these more ‘existential’ issues about EHRs can be worked through. (I don’t expect to see that in my life time I have to say!)

We should aim to do the absolute basics well - and use a very constrained information model, recognising all the limitations, - and when, and only when, that is all working reliably with broad coverage then start on Phase 2!

I would love to know what others think. Are there other ways to skin the transfer of complex, subtle health information cat?

David.

Postscript:

After finishing this I came upon even more relevant commentary.

The previously mentioned Grahame Grieve has written up some thoughtful comments on the value and fate of "HL7 Version 3", the latest Health Level 7 Standard from a pro and con perspective.

HL7 V3 has Failed: www.healthintersections.com.au/?p=476

And

HL7 V3 has Succeeded: www.healthintersections.com.au/?p=482

All this is starting to make my head hurt!

D.