Health care’s new commodity

You’re at the doctor’s office and the nurse or medical assistant is assessing your vital signs. Weight, height, temperature, blood pressure, pulse – each is measured and silently written down.

What’s missing from this picture? The sharing of information, that’s what. Are the patient’s vital signs a matter for the clinician’s eyes only, or are they something that also should be shared with the patient? Because all too often, whether it’s in the exam room or at the hospital bedside, the information goes straight into the medical record while the patient is bypassed.

I’m not trying to single out the people who take vital signs or suggest that they’re deliberately withholding information from the patient. This just happens to be an example I’ve noticed of a pattern that seems ingrained in health care culture: the assumption that the information doesn’t really need to be shared unless the patient specifically asks for it.

Late last week I was drawn into an online debate at Mind the Gap, a doctor-patient communication blog hosted by Steve Wilkins.

Wilkins opened with a basic premise: that the fastest way to disempower, de-activate and disengage patients is a trip to the doctor’s office. He writes:

If you were to believe the admonitions of the NIH, AHRQ, hospitals, pharma and every WebMD lookalike, you would think that patients these days would be more involved in their visit… asking questions, sharing information and making decisions. But as most physicians will attest… most patients don’t have much to say in the exam room anyway. And the longer they have to wait before being seen, the less patients are likely to bring up the few questions they wanted to ask.

Predictably, the responses were divided into doctors-are-incredibly-pressured-and-doing-the-best-they-can vs. patients-feel-shut-out-and-are-sick-of-fighting-for-every-scrap-of-knowledge-about-their-health.

While there are numerous factors contributing to this less than optimal state of affairs, at least some of it seems to stem from a playing field that simply isn’t level when it comes to sharing information.

One of the commenters said she asks questions in the doctor’s office and asks for copies of her medical record. “I ACT LIKE an empowered patient,” she wrote.”But it’s only possible to BE an empowered patient when the doctor is an active part of the process. An empowered patient can ask questions. That doesn’t mean that the doctor will provide an answer. An empowered patient can request notes and test results. No guarantee that those will be provided either.”

There’s in fact a new commodity in health care these days: information. Clinicians have it; patients want it. And therein lies a constant source of misunderstanding, frustration and defensiveness on both sides.

Patients chafe at the hoops they’re often required to jump through in order to obtain their medical information. This isn’t just their perception. Among complaints alleging violation of the federal HIPAA law governing the privacy of patient health information, problems with access to the medical record consistently rank No. 3 on the list of the top five violations requiring investigation and corrective action.

For their part, clinicians are under intense pressure and often can’t spend the time they’d like to share information more fully with patients. A physician commenter at Mind the Gap wrote:

This is the reality of today’s primary care office visit. 15 minutes: 4 minutes used for data entry into the EMR (has to be completed by the time the patient leaves); 3 minutes for entering lab orders and referrals; 90 seconds for reviewing health maintenance needs that have no relation to the visit at hand; 60 seconds for prescription reconciliation; THEN the six active problems can be addressed. There is no time for communication for any type, much less patient-centered communication!

Yet if you look at the research, it suggests many patients leave the doctor’s office with an incomplete understanding of key information such as what their diagnosis is or why they need a particular medication.

It’s true that for some patients, this simply might be more information than they’re able to absorb. This can’t be assumed for all patients, though. And it’s hard to see how patients can help make the most of limited time with their doctor when the default strategy is to give them minimal information in the belief that they don’t need more or won’t know how to use it.

What to do? Ironically, there’s more health information available than ever before. Consumers can go online and research their diagnosis. They can connect with other patients. They can check out the quality of their local hospital. They can rate their doctor. But none of this means very much when patients still often struggle for access to some of the most important data of all – information about their own health.

The healthy Internet

How often do you turn to the Internet to find health information? If you’re like me, it’s normally the first resource you seek out.

According to some interesting new data from Google, this is far from unusual. Mary Ann Belliveau, Google’s health industry director, recently guest-blogged at CNN about the rise of health information-seeking on the Internet. Among the statistics she shared:

- Health information is “one of the web’s most popular topics.”

- A Google-commissioned study by the research and consulting firm OTX found high use of the Internet among people who researched their conditions online before talking with their doctor. I’ve been unable to find any data on the actual size of this survey or how it was conducted, so the findings are somewhat vague. Here are a couple of key data points, though: The proportion of respondents who looked for information online before seeing their doctor was 75 percent, and 70 percent of the respondents also researched online afterwards to learn more.

- Online search engines were the tool most people turned to first.

- 37 percent of the respondents said they did health-related Internet searches at least once a week.

What information do people most want to find? Belliveau writes: “The No. 1 thing we hear from patients and caregivers is a desire to hear from people in situations similar to their own.”

If the study results are any indication, people aren’t passive about how they use the information they find online. Belliveau writes that 55 percent said they changed their lifestyle or behavior, 52 percent made a self-diagnosis, 49 percent started an over-the-counter treatment, and 46 percent told a doctor about a symptom they or someone else had.

This interest in health-related information also extends to social media. According to the survey, the health category on YouTube was more popular than sports, food or celebrities.

A couple of thoughts come to mind: First, although physicians often gripe about patients who get their health information on the Internet, it’s a phenomenon that’s widespread and won’t go away any time soon. If anything, it likely will become the standard, default behavior among a younger generation that has grown up taking Google and the Internet for granted. Rather than fighting it, health care professionals need to learn to live with it and figure out how they can incorporate it in a way that’s constructive.

Second, the Internet is a bottomless pit when it comes to health information – some of it accurate and worthwhile information but some of it unhelpful, misleading, or overly generalized. Some websites purport to offer health information but in reality are thinly disguised marketing ploys. And sometimes the information that can be found online has no basis in science whatsoever and might be downright harmful.

Some consumers can separate the wheat from the chaff and navigate all of this on their own. Others need help learning how to judge a website’s credibility and what questions to ask. And there’s a whole contingent of consumers who probably just want to be pointed toward one or two of the best websites that contain the information they need.

The Google consumer survey underscores another critical issue: People can and do take action based solely on what they read on the Internet. Reputable providers of online health information need to understand this and make every effort to be accurate and transparent.

No one seems to have clearly defined what the role of medical providers should be in steering consumers toward reliable online resources or helping them understand what they read online. Nor has there been any clear delineation of the responsibility consumers ought to bear for using online information wisely. Maybe it’s a conversation we need to have, sooner rather than later.

HealthBeat photo by Anne Polta

In pursuit of the EMR

Maybe bonus payments will do it – speed the transition to electronic medical records, that is. Last week the Centers for Medicare and Medicaid Services announced plans to distribute billions of dollars’ worth of stimulus payments to doctors and hospitals who make the switch from paper to digital medical records. Standards are in the process of being developed and are currently open for public comment. Once the standards are finalized, eligible hospitals could start receiving incentive payments by October. Other eligible providers, such as physicians, could get their bonus payments starting next January.

The money itself was authorized as part of the American Recovery and Reinvestment Act of 2009, which allocated $19 billion in stimulus funds to spur the adoption of electronic medical record technology.

Despite all the technologic advancements in medicine, the industry as a whole has lagged far behind everyone else when it comes to information technology. By some estimates, fewer than 20 percent of physician clinics use electronic charting for their patients; all the rest still rely on old-fashioned paper records.

There are a lot of reasons why health care hasn’t rushed to the forefront to embrace information technology in patient care. For one thing, health care is complex, so it’s no easy matter to develop workable – and affordable – software programs that can do everything that’s needed. What a hospital emergency room or radiology department might require, for instance, vs. what a physician office practice might need can be two very different things.

Well-designed programs have been slow to be developed, although the pace has been quickening in just the past few years. A frequent complaint has been the use of electronic templates which, depending on your point of view, can either help streamline and standardize the charting process or can get in the way of adequate, thorough documentation. Another issue is compatibility with other programs so hospitals and clinics can electronically “talk” to each other and share patient records.

Cumbersome hardware has been one of the barriers as well. If you run a physician office practice, do you go to the expense of installing a computer in every exam room? If you’re a hospital, should you have a computer at every bedside? Or do you lug a laptop or electronic notebook or some other portable gizmo from one patient to the next?

There’s no getting around the fact that the EMR is an expensive investment for health care organizations. On top of the money they’re spending, they also have to consider the cost of training and the inevitable headaches and lost productivity associated with implementing an EMR system and working through the glitches.

And let’s face it, plenty of physicians are unhappy with their experiences so far with the electronic medical record. At least one recent study suggests the EMR hasn’t lived up to its promise of offering better patient care at a lower cost – although the study’s authors also believe many organizations simply aren’t using their EMR systems to their full potential. A recent online gripe session at Kevin, MD, made it clear how some physicians feel about the push toward the electronic medical record. “If these were good products, they would sell themselves without incentives and such,” one physician wrote. “It is becoming clear that the EMR emperor is wearing no clothes. The current sales pitch can be translated, ‘Yes, we know they’re lousy products, but the government is going to require them, so you better buy one now.’”

In spite of all the challenges and drawbacks, plenty of health care organizations have already forged ahead with the EMR. One of the earliest adopters was Family Practice Medical Center here in Willmar. Affiliated Community Medical Centers also has been making the transition, starting a few years ago with electronic prescribing and expanding in stages. Ditto at Rice Memorial Hospital, where a new EMR system in the emergency room and electronic charting at the patient’s bedside were both implemented within just the past couple of years.

It hasn’t been easy. It has taken a lot of work and a lot of planning, not to mention the commitment that this is the direction in which these organizations want to go. It’s also still a work in progress, with problems yet to solve and new applications yet to learn.

To be sure, Minnesota is farther ahead than many other states in implementing the EMR. A year from now, a new e-prescribing mandate will take effect, requiring all prescriptions to be ordered, filled and paid for electronically. The state’s so-called e-health initiative also requires all Minnesota providers to adopt an electronic medical records system by 2015. The goal, laid out by the public-private collaborative that’s leading the e-health initiative, is “to accelerate the adoption and use of health information technology in order to improve health care quality, increase patient safety, reduce health care costs and improve public health.”

Will Minnesota get a piece of the action when the federal stimulus funding starts being doled out later this year? Let’s hope so. More to the point, let’s hope local providers will receive some incentive payments for what they’ve already been doing. They’ve been at the forefront, bearing the brunt of the risk and the hard work so that others can follow after them – and this ought to be worth something.

West Central Tribune file photo by Bill Zimmer.

Drinking from the fire hose

On a daily basis, it seems, we’re deluged with health information. The Internet, the availability of instant e-mail communication and the 24/7 news cycle have created a torrent of stuff for people to wade through, and the newsroom here at the Tribune is no exception. In fact, of all the reporter beats we cover, health care (and politics) are the most laden down with a never-ending stream of information.

During the first seven days of October, I decided to keep track of all the unsolicited health-related e-mails I received. The picture above shows what my inbox looked like by Thursday. There were 84 health news e-mails in all, not counting those that ended up in my spam filter or the rest of my e-mail.

There were more than a dozen about influenza, the H1N1 influenza virus and flu vaccination. This being Breast Cancer Awareness Month, there were at least half a dozen news releases about breast cancer. There were news releases about eye safety, obesity, the relative benefits of green matcha tea vs. ordinary green tea, and managing the side effects of antibiotics. There were a couple of pitches for homeopathic diets. A plastic surgeon in Beverly Hills (his PR firm, actually) sent an e-mail plugging his new book on cosmetic surgery. I received an invitation to a conference on bioinformatics for medical devices and biopharmaceuticals.

I’m in a relatively small newsroom in rural Minnesota. I can’t imagine the amount of material the New York Times or the Boston Globe or Washington Post receives in a single day.

Most of us, I think, are super-saturated with information, especially when it comes to health care. There’s so much information from so many sources, it’s like trying to drink from a fire hose.

For the media, it’s a continual struggle to sort through so many potential stories, knowing there’s neither the time nor the resources to do them all, let alone in the depth they often require.

Those who work directly in health care are challenged every single day to keep up with the constant flow of new information. Patients can get frustrated if they perceive their doctor isn’t up to date on all the latest developments or can’t give them definitive answers, but the reality is that the state of medical knowledge is a continually moving target. New drugs are introduced. Studies are issued that change the course of how a disease is managed. Hitherto-unrecognized risks are identified or redefined. New diseases emerge. Experts disagree. Knowledge continues to evolve.

MRSA, or methicillin-resistant staphylococcus aureus, is a case in point. At one time it was seen mainly among people who spent a lot of time in hospitals and/or nursing homes. Then cases began showing up among people who were otherwise healthy, and we now have a new disease category and set of risk factors known as community-associated MRSA.

Another case in point: the new H1N1 flu vaccine. A lot of people are wondering: Is it safe? Some doctors have been hesitant to recommend it; other health experts are urging parents to have their children vaccinated. With so much conflicting and confusing information, it’s no wonder people have grown distrustful, as evidenced in the discussion this week at the New York Times Well blog. "Myself, my husband, and our small child will not be guinea pigs for Big Pharma," one woman declared.

Where, in fact, does this leave the public? Is there such a thing as too much information? For many people there probably is, although where this line should be drawn is different for everyone. And the sheer volume of information isn’t the only issue; there’s also the question of how to sort through it all and interpret it and understand it. Not everyone is able, or willing, to do this. Moreover, there seems to be a growing inability among the public to tell the difference between fact, opinion and speculation, and it can lead to some very mistaken conclusions.

In spite of all this, I’d still argue that when it comes to health care, information is a good thing. Most consumers are better off when they’re educated and informed and engaged in their health. Most of us don’t want to go back to the days of medical paternalism, when information was a commodity that was anything but equally shared. Maybe drinking from the fire hose is a trade-off we have to accept in exchange for leveling the playing field.

HealthBeat photo by Anne Polta