"Interest Online Smoking Cessation Program - Project Results"
"Remote Control for Health Care"
"Hospitals to implement health information exchange system"
"Brailer says IT could cut healthcare costs in half"
"Technology helps patients take charge of health"
"Face to face with the future of remote medical consultations"
"Physician Care and Telemedicine"
"Internet Visits With Doctors Can Beat Office Appointments"
"Healthcare Interoperability: the big debate"
"Electronic Records Are Key to Health-Care Reform"
"A Tale Of Two Large Community EHR Extension Projects"
"5 Myths on Health Care's Electronic Fix-It"
"3 Ways Tech Can Help Hospitals Collect"
"Care Management in the Digital Age"
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Care Management in the Digital Age: The Advantages of Real-Time Patient Data in the Home Reducing Hospital Readmissions, Promoting Collaboration, and Keeping Patients At Home
By Jane Fields and Melody Wilding
Dec, 2012 - Case In Point magazine
Generating real-time data from a patient’s home is an integral component of providing comprehensive care management. New technologies that enhance management and coordination of care for seniors and patients with chronic conditions will become indispensable tools supporting care management models. As the digital communication of healthcare information becomes ubiquitous, using technology within a home-based care management model is key to optimizing care quality, easing the burden of overwhelming caseloads, and reducing costs.
While a patient may spend a few hours in a doctor’s office and several days in the hospital, the majority of a patient’s time is spent at home. In-home technologies that provide digital health monitoring and tracking enable care managers to monitor patients and respond to their conditions in real time, supporting care coordination that focuses on providing the most appropriate response at the lowest cost.
For example, the eCaring in-home health record system enables home care aides, family caregivers, and patients themselves to enter enormous amounts of realtime healthcare data, regardless of their computer skills or healthcare literacy. This information ranges from medication intake and vital signs to daily routines and even state of mind.
In essence, digital tools that capture such comprehensive information help establish a baseline for normal functioning. Deviations from this baseline can then be tracked on a moment-to-moment basis. Web-based dashboards with a patient’s health status and care patterns can be easily viewed, analyzed, and acted upon by the care team – all in real time. Also, the system can alert case managers of significant events, such as a fall, repeated meal refusal, dangerous weight gain or blood sugar increases, prompting an immediate response Being able to monitor a patient’s vital signs, compliance with plans of care, and adherence to medications enables better control of chronic conditions and early intervention. This knowledge prevents further deterioration and also allows case managers to improve the quality of services provided to clients and manage their caseloads more effectively.
With all these factors in mind, we can expect that a digital healthcare record from the home of a senior or a person with a chronic condition will radically change healthcare outcomes for the better.
REDUCING PREVENTABLE HOSPITAL READOMISSIONS
Research shows that 75 percent of Medicare hospital readmissions may be preventable. In fact, readmissions in 30 days or less account for one in nine readmissions. The total cost for these repeat hospital stays is estimated at $30.8 billion. Receiving actionable data from the home is key to reducing emergency room visits and avoidable hospital readmissions for an especially high-risk population of seniors and individuals with chronic illnesses. In addition, eCaring’s unique integration of in-home clinical and behavioral data helps care managers determine who is at risk for readmission, buffering hospitals from expensive Medicare penalties. It enables patients to live at home longer at lower costs, lowering the burden on themselves and their families.
Optimizing high-cost services
What’s more, care managers can use patient data gathered from the home to stratify levels of response and corresponding treatment costs. This process differentiates cases that can utilize lower-cost services, such as a phone call or physician visit, from those cases that require high-cost emergency response and hospital-based intervention.
This form of evidence-based decision support previously hasn’t been available to healthcare professionals, as there was no means to gather the critical in-home data.
PROMOTING COLLABORATION AND THE EXCHANGE OF ACTIONABLE DATA
Care management organizations, such as accountable care organizations (ACOs), patient-centered medical homes (PCMH), health homes, and managed long-term care entities (MLTCs), are a fundamental and growing part of the healthcare ecosystem.
These organizations require technology for reliable communication, and information systems for facilitating their services. Leveraging real-time patient data generated from inside a patient’s home creates an information flow that continues after a patient leaves the hospital, allowing for ongoing treatment and immediate response to medical or behavioral issues.
Real-time data generated from within the home promotes collaboration among the care team, allowing multiple parties to stay informed about a patient’s condition. Providers, including physicians, insurance caseworkers and nurses, and family caregivers can work together to make decisions concerning patient care.
In-home health record systems offer critical health-related information that is formatted to fit within a case manager’s or care coordinator’s workflow, streamlining administration and improving productivity through efficient management.
DELIVERING THE FULL PICTURE OS CARE
Real-time care information from a patient’s home provides a comprehensive picture of care, helping care managers and providers treat conditions in a complete fashion, rather than in a fragmented manner over time. Unlike telecare systems of previous generations, eCaring’s in-home health data systems can record not only vital signs like blood pressure and weight, but also provide insight into the factors and actions that lead to these readings. For example, a reading showing high glucose levels provides little help in determining the best course of treatment. However, combined with dietary patterns, a medication intake calendar and an activity log, this information helps healthcare providers to adjust the plan of care and offer a customized healthcare solution.
KEEPING PATIENTS AT HOME, WITH COMFORT AND SAFETY
Using real-time clinical and behavioral data generated from a patient’s home keeps the patient at home longer, potentially saving the country billions in healthcare costs over the coming decades. Real-time health data also reduces transitions to other, more expensive care settings including nursing homes, assisted living facilities, and rehabilitation centers. Keeping patients at home boosts patient satisfaction while reducing caregiver stress. In a survey by AARP, 89 percent of people over the age of 50 reported that they would prefer to age-in-place at home.
Empowering families with real-time, vital care information available on their smartphones or tablets gives them the confidence that their aging parent, or a loved one with a serious chronic condition, can remain at home safely and in greater comfort.
The benefits of web-based, real-time patient data gathered from within the home are far-reaching and have major implications for improving safety and quality of life for patients, while also reducing system wide healthcare expenditures. As patient advocates, it is time for us to step into the new age of care coordination by embracing digital personal health record systems from the patient’s home
Gienna Shaw, for HealthLeaders Media, September 20, 2011
The way Americans pay for healthcare services is changing—and as a result healthcare providers will be forced to take on new or expanded roles as benefits educators and administrators, financial counselors, creditors, and collectors.
HealthLeaders recently convened a panel of experts in Boston to discuss how healthcare organizations can adapt to the new landscape. We talked about a range of topics—from patient financing to outsourcing collections to honoring your mission and protecting your brand while you mind your bottom line.
One theme that emerged during the discussion: Technology can help healthcare organizations with many of the collections issues they face. Panelists discussed three ways technology can enhance the collections process.
1. Educating patients
Insurance models are becoming more and more complex—high deductible plans, co-pays, co-insurance, and different tiers of coverage can confound patients. So who will be responsible for education? And how can technology help?
"It's challenging from a patient education perspective: telling patients why they owe more money than in the past, interpreting new rules, helping patients into the right programs, and helping them understand those programs," said Thomas Yoesle, chief operating officer patient financial services at Orlando Health.
"Technology can play a huge role in helping consumers understand their plans, their benefits, and the amount they must pay out of pocket," added Deborah Lelinski, Director Product Management at Ontario Systems, which sponsored the roundtable event. "Right now, it's very difficult to realistically predict the cost of service when the complexity leads us to answer with 'It depends.' "
Meanwhile, online education has its benefits, but face-to-face interactions might be important as well, Yoesle said. "As much as I want to push this education and information to the Web, I think we'll start hosting workshops and using kiosks to answer questions about benefits and plans and then push those FAQs to the Web."
Richard O'Donnell, vice president of payer strategies and contracting at Trinity Health also noted that insurance exchanges could take on the role of interpreting benefit design.
Even so, said Timothy Reiner, vice president of revenue management at Adventist Health System, "we're still going to have to engage the patient in different ways once those exchanges become more prevalent in the various states in 2014. It may be online portals or other strategies. There is a lot we don't know, but clearly one of the tenets of meaningful use is to engage the patient more online in their care—including their financial responsibility."
2. Estimating payments
When you walk out of a dentist's office, the person at the front desk has a pretty good idea what you'll owe—and it's rare a patient walks out the door without paying at least part of it.
So why not in hospitals and physician's offices?
"Estimating benefits is something that we've struggled with from the Stone Age," Reiner said. "As a provider, you've got to decide whether to invest in additional technology beyond just pushing a button and sending a transaction to the payer or screen scraping [capturing computer screenshots and putting them into a database]. We should be so much better than this."
"We need what I would call real-time patient liability estimators—complete interconnectedness between health plans and the clearinghouses and the providers," O'Donnell said. "Patients should be able to log onto a portal to determine their unmet liability, he said, even if that means adding disclaimers that it might not be 100% up-to-date." It's so much better than having someone asking 20 questions to identify your possible out-of-pocket liability that may still be inaccurate."
3. Securing payments
At a hotel, your bill is computed before you check out—usually they've slipped it under your door in the night. And there's no walking out the door without settling up. So how can technology help hospitals catch up to dentists and hoteliers?
"As we move toward more EMRs, documentation will drive the charges," Reiner said. "If you're documenting a level 3 evaluation and management visit, you know that by the time the patient is ready to walk out the door. That claim could be adjudicated, as with the pharmacy model, and you would know your co-pay is $35. There's no reason that episodic physician visits can't be done like that.
Inpatients are a little different, but the only reason that it can't be done is because the payers don't offer it and there's not a singular work flow for it."
But what about the risk that physicians will miss a charge if they don't properly document the visit?
Reiner says he's willing to take it. "If we made a charge capture error, we'll take our lumps. It would be better to miss a charge but get the payment at time of service."
Are electronic health records the panacea for all our health-care ills? Congress seems to think so: With strong cheerleading from President Obama, it has approved $20 billion for EHRs as part of the stimulus package. Health information technology undeniably holds a lot of promise, but it's still in its infancy. Is it worth a stimulus now? A look at some health IT myths:
1. Electronic health records will cure our health system.
EHRs will potentially provide a lot of benefits, most notably by reducing medical errors -- e.g., doctors prescribing medications to patients with an allergy to them -- that kill as many as 98,000 Americans each year. A much-cited 2005 Rand Corp. study of EHRs found that they could save $77 billion annually and potentially eliminate 200,000 adverse drug reactions. Yet a more recent analysis, by Stephen Parente and Jeffrey McCullough in Health Affairs, found that "the evidence base is not yet sufficient" to show that EHRs would improve outcomes.
Implementing EHRs to improve billing -- which would be the simplest and least creative way to spend Congress's money -- is not enough. EHRs can improve our system and help achieve the assumed cost savings only if they bring about changes in the way we practice medicine. Doctors have extremely limited time with their patients. EHRs would help by giving them access to the patients' documents, including all previous tests and conditions, in advance, and by allowing patients to communicate with physicians via e-mail. With the right kind of EHRs, doctors could obtain real-time guidance on the best care for a specific patient from databases containing all the latest diagnostic and therapeutic guidelines.
But this technology is evolving rapidly, and implementing systems in the right way will require thoughtfulness and creativity. As pediatrician and health IT expert Kenneth Mandl, who co-wrote a skeptical analysis of subsidizing EHRs for the New England Journal of Medicine, told the New York Times, "If the government's money goes to cement the current technology in place, we will have a very hard time innovating in health care reform."
2. Federal carrots and sticks are the only way to get doctors and hospitals to adopt EHRs.
It's true that far too few doctors and hospitals have electronic systems in place. The Congressional Budget Office has estimated that about 12 percent of physicians use them. According to a recent study in the NEJM, only 1.5 percent of U.S. hospitals have a comprehensive electronic records system available in all clinical units, and another 7.6 percent have a basic system available in at least one clinical unit. Seventeen percent of hospitals let doctors prescribe medicines electronically.
The stimulus package established 10-year EHR adoption goals of 70 percent for hospitals and about 90 percent for physicians. But even without the stimulus, the CBO estimates that 45 percent of hospitals and 65 percent of physicians will have EHRs by 2019. In other words, many doctors and hospitals are likely to adopt electronic systems even without the subsidies, which begin in 2011, and the potential penalties for failing to adopt, which are expected to begin in 2016.
3. Cost is the only reason the United States has such low adoption rates.
The initial capital investment in EHRs, estimated at between $15,000 and $50,000 for a practice and $10 million for a midsize hospital, is definitely a deterrent, but there are other reasons for delay. On the economic side, the financial incentives in medicine don't reward doctors for performance, so improving performance with EHRs is not a necessarily a priority. Cultural issues, especially among older doctors, are also a big obstacle. A 2008 study sponsored by the Department of Health and Human Services and the Robert Wood Johnson Foundation found that 29 percent of non-computerized hospitals cited doctor resistance as a major barrier to adopting health IT, and 42 percent claimed it as a minor barrier. David Blumenthal, the Obama administration's recently appointed health IT czar, wrote in the NEJM that beyond cost, the barriers to adoption of EHRs include "the perceived lack of financial return from investing in them, the technical and logistic challenges involved in installing, maintaining, and updating them, and consumers' and physicians' concerns about the privacy and security of electronic health information."
4. Subsidizing EHRs will stimulate the economy or EHR adoption in the short term.
The stimulus package contains bonus payments of $44,000 to $64,000 to physicians who adopt and use EHRs effectively, beginning in 2011 and continuing through 2015, with the largest total spending taking place in 2014. After that point, doctors who do not use EHRs may be penalized. But even if the law called for the money to be spent earlier, the Department of Health and Human Services is not yet close to being ready with the payment rules, certification standards or definitions of key terms such as "meaningful use," which are called for by the end of 2009. Federal encouragement of EHRs could actually serve as an anti-stimulus, because IT companies could be reluctant to develop new products until the government sets the certification standards. Furthermore, doctors and hospitals, seeing the promise of federal dollars 20 months away, will be unlikely to buy new record systems until the government money starts to flow.
5. We know how much we're investing in this effort to promote health IT.
The media typically describes the investment in EHRs as $20 billion. But this doesn't count $12 billion in estimated savings for EHR adoption that may or may not happen, so the real number is closer to $32 billion. And the $32 billion is only an estimate, since the bulk of the stimulus dollars for health IT is in what is known as mandatory spending, meaning that the money is paid out as long as applying doctors and hospitals meet the appropriate requirements. So the actual number could go as high as $50 billion or even higher. This is unsurprising, since Obama called for an investment of $20 to $50 billion in health IT on the campaign trail. So we may not know the actual amount -- but in Washington, it's always a good idea to bet on the higher number.
Tevi Troy, deputy secretary of the Department of Health and Human Services from 2007-2009, is a visiting fellow at the Hudson Institute.
ACHIEVING MORE WIDESPREAD ADOPTION of electronic health records (EHRs) is a key component of health reform at the state and federal levels. However, adoption of EHRs is low: only 4 percent of providers have fully functional EHRs with decision supports and order-entry management, and 13 percent have more basic systems.1 Smaller practices (1–3 physicians) have even lower rates of adoption of fully functional (2 percent) or basic (7 percent) EHR systems. Key barriers to EHR adoption reported include financial concerns (for example, the amount of capital needed, return on investment, productivity loss during implementation); difficulty finding a system that meets stated needs; and lack of technical capacity to select, contract, install, and implement such a system. Recently, there have been a number of efforts to overcome these barriers in consortia of community health centers (CHCs) and independent physician organizations and through hospital sponsors.2 The Massachusetts eHealth Collaborative (MAeHC) and the New York City Primary Care Information Project (PCIP) represent two successful examples of a new approach. These projects subsidize EHR implementation costs, provide central project management and practice consultation, and require participation in the program’s public-interest goals in a defined geographic area. Within a short time, these projects have achieved the widespread adoption of EHRs across hospital-owned and multispecialty clinics, CHCs, and solo and small practices.
As the Centers for Medicare and Medicaid Services (CMS) embarks on its pilot to establish small practice demonstration projects in twelve communities, and with the possibility of sizable investment in health information technology (IT) in the Obama administration, we provide the first detailed descriptions of both large-scale EHR projects, and we offer perspective on contrasting approaches and lessons learned.
The Massachusetts eHealth Collaborative
Origins. MAeHC is a nonprofit company launched in 2004. With a mission of "facilitating ubiquitous adoption of EHRs in the Commonwealth of Massachusetts," MAeHC has roots in the physician leadership of the Massachusetts chapter of the American College of Physicians and the Massachusetts Medical Society, and a $50 million financial commitment from Blue Cross Blue Shield of Massachusetts. These three organizations built a coalition of thirty-four nonprofit organizations, which represent the entire health care delivery chain in Massachusetts—from health care purchasers to insurers to providers to patients—that now constitutes the collaborative’s board of directors.
Community-based focus. MAeHC launched three pilot projects to demonstrate the costs and benefits of wide-scale EHR deployment, understand the barriers to adoption of EHRs and health information exchange (HIE), and test an organizational model for managing and executing communitywide use of EHRs and HIE. Lessons learned from these pilot projects will be applied to a statewide approach to deploying EHRs and HIE.
On 6 December 2004, MAeHC began recruitment for its pilot projects, eventually choosing three communities from among thirty-five applicants: greater Brockton, greater Newburyport, and northern Berkshire County (North Adams). MAeHC focused on health care delivery markets: each area includes at least one acute care hospital, along with ambulatory care specialists and primary care providers who refer patients to each other and to the acute care hospital(s). This approach aligns patients’ care patterns and creates a foundation for better-coordinated care and meaningful HIE. The natural shared experience and interactions among providers in the community is beneficial for mutual support and learning, and for aligning clinical workflows as they adjust to the new systems.
Building an organization. MAeHC was designed from the outset to be both lean and scalable, to meet the demands of statewide implementation. The organization is comprises the following: (1) senior relationship managers, who work with community leaders to provide community focus and a collaborative approach to the local program; (2) practice consultants, who work as "navigators" in individual practices to provide overall project management and facilitate workflow redesign, system configuration, tailored training, and postimplementation training and support; (3) project managers, who coordinate activities at the project level to ensure discipline, tracking of project milestones, identification of issues that arise, and coordination of efforts among vendors; (4) technical managers, who provide technical expertise and management to the design, deployment, configuration, and support for both the system and its interfaces; and (5) other key functions, such as database management, evaluation, communications, accounting, and bookkeeping.
Choosing vendors. MAeHC’s goal in selecting vendors was to deploy high-quality, off-the-shelf EHR systems, rather than to obtain a customized EHR. Although the goal of high adoption rates suggests allowing providers some choice of systems, the need for interoperability meant that the number of choices needed to be limited. MAeHC chose four vendors from more than twenty proposals: Allscripts, GE Centricity, eClinicalWorks, and NextGen. All four systems have been deployed in the MAeHC pilot projects. The design and configuration of hardware was managed centrally by MAeHC technical experts and an integration vendor, Concordant.
Current status. MAeHC’s first practice went "live" in March 2006. Over eighteen months, MAeHC brought 97 percent of the participants (nearly 600 physicians) onto EHRs. MAeHC’s implementation approach used practice consultants to guide each practice through implementation and postimplementation assessment and assistance. MAeHC monitors usage of systems through automated electronic reports, which allows MAeHC to identify providers who are not using the systems, to help improve adoption rates. Providers who do not use the systems are dropped from the program and required to pay financial penalties, as stated in their participation agreements with MAeHC.
With generally high usage of the systems (more than 90 percent of providers are doing electronic clinical documentation), MAeHC’s postimplementation focus has been on (1) improving the adoption of providers with low usage; (2) getting more physicians to use more EHR functions; and (3) aligning clinical documentation across providers, to allow better performance measurement and feedback.
Although the pilot projects formally ended in December 2008, MAeHC is maintaining relationships with all participating providers through 2010, to allow ongoing collection of performance and evaluation data. The MAeHC Quality Data Center (QDC) was created in partnership with the Massachusetts Health Quality Partners, a "broad-based coalition of physicians, hospitals, health plans, purchasers, consumers, and government agencies working together to promote improvement in the quality of health care services in Massachusetts."3 The QDC now aggregates and analyzes clinical information from all deployed EHR systems and generates feedback and patient action reports to physicians via Web-based tools. Looking forward, Massachusetts has appropriated $25 million to launch a statewide EHR deployment program to follow the pilot projects. MAeHC hopes to be selected by the state to implement the statewide program.
The New York City Primary Care Information Project
The New York City Primary Care Information Project (PCIP) was created as a mayoral priority initiative in 2005 and is part of the city’s Department of Health and Mental Hygiene. It seeks to improve population health in disadvantaged communities through health IT. The City of New York contributed $30 million in start-up funds, and PCIP leveraged an additional $28 million from state, federal, and private sources.4
PCIP focuses on three areas: (1) information systems oriented toward prevention; (2) changes in care management and practice workflows; and (3) payment that rewards effective prevention and management of chronic disease.5
Developing and deploying a quality-focused EHR. In 2005, only three of twenty-nine CHCs in New York City were using EHRs. PCIP’s first priority was to ensure that all twenty-nine would have access to an EHR by the end of 2009. These health centers serve approximately half a million New Yorkers, more than 75 percent of whom are on Medicaid or uninsured. A health center consortium chose four eligible EHR systems. Over the past two years, nine additional health centers have adopted one of these EHRs.
The city undertook a rigorous process to select a single vendor. In March 2007, eClinicalWorks was selected to develop the Take Care New York EHR, because of its product quality (modern architecture, flexibility, security) and capabilities (including its track record in MAeHC). This includes standardized clinical data elements, registry functions that generate lists of patients for outreach, automated clinical quality measurement, decision support, and patient self-management tools. PCIP is also investigating possible communication between public health organizations and EHRs to improve mandated reporting of communicable diseases, immunization records, school health, and real-time surveillance of illness trends. It is hoped that the new functionality provides the blueprint for the rest of the ambulatory EHR market to match or surpass.
The city is granting eligible practices (primary care providers with more than 10 percent Medicaid and uninsured patients) a package of software and services (licenses, training, data interfaces, and two years of maintenance and support). Practices must contribute to a quality improvement fund and bear the costs of hardware, IT installation and support, Internet connectivity, and productivity loss during implementation.
As of 1 October 2008, PCIP had recruited more than 1,400 providers to adopt the EHR system. Of these, 843 are currently "live" on the EHR, and approximately 80 providers a month are going "live" on the system.
Supporting office redesign and quality improvement activities. PCIP implementation services include assistance with organizational readiness and IT infrastructure assessments, project management, analysis of clinical workflows, development of interfaces with labs, data quality assurance testing, and vendor relations. Staff has also developed EHR training curricula with sixteen hours of continuing medical education credit.
After each practice goes "live," additional staff work to ensure that providers can use the system effectively. Billing and EMR consultants help practices with system configuration, troubleshoot problems, and teach best practices. Monthly on-site quality improvement visits cover registries for planned care, effective performance feedback, team-based care strategies, patient education, and self-management support. For practices that are interested in Patient-Centered Medical Home certification from the National Committee for Quality Assurance (NCQA), PCIP is facilitating their efforts.
Creating a framework for a pay-for-prevention system. Using the integrated EHR system, providers can generate clinical quality measures about the care they deliver to their patient population. As part of their agreements with PCIP, practices send summarized quality measures (numerators, denominators, and exclusions) to a citywide Quality Reporting System (QRS), where they will be able to compare their performance with other similar providers confidentially and securely. PCIP is working with Bridges to Excellence and other stakeholders to incorporate these EHR-derived quality data into a nationally recognized reward and recognition program.
Using funding from the Robin Hood Foundation, beginning in 2009 PCIP is also providing payments (up to $20,000 per physician) to EHR-enabled practices for every patient with well-controlled cardiovascular risks (known as the ABCs: aspirin, blood pressure, cholesterol, and smoking cessation), with higher bonuses for patients on Medicaid and the uninsured and for those with comorbidities (such as diabetes and heart disease).
Future plans. By 2010, PCIP plans to extend prevention-oriented EHRs to 2,500 primary care providers serving two million patients, including half of all Medicaid patients in New York City. PCIP is also planning to engage patients with EHR-linked personal health records. PCIP is working closely with the New York eHealth Consortium and several HIE organizations to enable the PCIP EHR network to participate in data exchange using standardized protocols.
There are important differences in the funding, governance, design, and structure of the MAeHC and PCIP projects (Exhibit 1). Many of these are a direct result of the projects’ different orientations. MAeHC emphasizes continuity of care within selected communities, and PCIP stresses improvements in preventive care and chronic disease management across a population. Here we describe some of the differences in more detail.
Outreach. MAeHC identified three intervention communities, with the goal of achieving 100 percent coverage of all practices (specialty and primary care) in a short time. The MAeHC approach of achieving nearly complete EHR penetration, in combination with HIE, emphasizes continuity of care. It serves as a microcosm of a future state in health care, enabling analysts to learn about the impact of EHRs on cost, quality, and efficiency of care within a community. One advantage of its approach is that the communities involved had organized on their own before MAeHC began and had their own nascent governance structures; this was helpful logistically, and it may promote long-term financial and organizational sustainability.
PCIP recruits primary care providers caring for the underserved across a large metropolitan area, aiming to enroll 25–30 percent of high-volume Medicaid primary care providers. The PCIP approach can maximize the impact of limited dollars to extend people’s life expectancy and reduce disparities among racial/ethnic and socioeconomic groups. It may also offer more precise guidance on the investment return of EHR adoption for public programs such Medicaid and Medicare.
Practice contributions. MAeHC covers all direct costs (hardware and software) associated with implementation and directly contracts for them. PCIP has covered only the cost of software and training, and it requires a $4,000 cash contribution per provider, which is placed into a quality improvement fund. Exhibit 2 compares the costs incurred in the two programs.
PCIP is moving toward MAeHC’s level of achievement by procuring a package of preconfigured hardware and IT integration for underresourced small practices, and by supporting CHCs in procuring additional funding for infrastructure. The MAeHC approach greatly reduces the problems associated with inadequate or inconsistent hardware and the lack of professional IT support. However, after the pilot period, the MAeHC practices may have difficulty sustaining the costs of ongoing software and hardware maintenance. The PCIP approach perhaps ensures a greater level of commitment from practices, and it permits the public agency to reach more patients at lower cost.
How many EHR vendors? MAeHC allowed practices to choose from among four vendors, while PCIP selected one. The reason MAeHC offers a choice is that different EHR software may be better suited to different ambulatory practices. However, selection of one vendor greatly reduces the complexity of vendor coordination and logistical support for the program, and it simplifies product selection for practices. Most of MAeHC’s practices chose one vendor, and PCIP’s single vendor has successfully deployed its solution across PCIP’s diverse settings. More important, PCIP’s approach created a closer vendor relationship with greater leverage, thus permitting the development of new implementation tactics, training approaches, and novel EHR software features that support prevention.
Lessons Learned: Why It Is Harder Than It Looks
Despite their differences, these community projects represent a successful new model for achieving a critical mass of EHR adoption within a short time. Their unprecedented success was possible because of spirited collaboration between practices, EHR vendors, the project staff, and external stakeholders. We have learned lessons that may have implications for policymakers and future community EHR extension projects.
Working with the community: a minority of implementation sites will consume the majority of resources. Community EHR projects include many practices that would otherwise not be adopters. These practices are excited to participate in the project and are committed both to professional excellence in caring for their individual patients and to public goals. However, many of these practices will not have the same readiness, resources, or early-adopter mindset of typical EHR customers. In three fictional vignettes, which appear in an online supplement, we have sought to illustrate some key determinants of successful adoption.6
A sizable minority of practices will face serious difficulties adapting to disruption in workflows, social dynamics, and revenue stream. These practices will consume the majority of attention and emotional energy from project staff. Not all difficult implementations are caused by lack of practice readiness; however, in general, practices that have pre-existing management problems, poor business planning, reluctance to make long-term investments, high staff turnover, and low staff morale will find EHR implementation very difficult.
To deal with this challenge, programs can take several actions.
Set expectations: Practices that volunteer for the program must have realistic expectations of the financial, organizational, and emotional stress involved. Practices that enter the program without these expectations will be surprised and overwhelmed by the burdens. Practices that are not ready to embark on these challenges (and not all practices are) should defer implementation until they are in a better organizational and financial state. Provide additional support: Beyond financial help, many practices will need comprehensive support services to assess readiness gaps, redesign workflows, provide additional training, troubleshoot technical issues, and communicate with the vendor when problems arise. The difficult part is doing all that while maintaining appropriate boundaries. Program staff should not take on responsibilities that reside with the vendor or practice. Facilitate a learning community: Practices may learn best from each other. Projects should establish mechanisms for community building (such as group training, user groups, and collaborative software). Building community means engaging not just the physicians but the entire clinical and nonclinical staff. At first, participants may want to voice their complaints, but productive problem solving eventually will follow. Know when to give up: Up to a third of IT implementations fail. In each of our projects, implementation at a few practices has been so troubled that the critical element of mutual trust was lost. Typically, all parties contributed to the problems. Sometimes, however, it is better to stop the ongoing crisis and mutually agree agree to sever ties. Although that is a frustrating outcome for all parties, practices with a failed implementation are likely to be more prepared for the challenges on their next try.
Working with EHR vendors: making the case for scalable solutions. Projects can conduct group purchasing of goods and services such as Internet access with higher quality of service, IT support, hardware, and shared infrastructure (for example, a data center). But the most challenging and rewarding aspect of communitywide EHR deployment is the creation of scalable solutions.
The technical, managerial, and outreach capacity of community projects allows EHR vendors to engage with these communities as they cannot with hundreds of individual practices. The vendors in these efforts have given the projects tremendous commitment; flexibility; dedicated staffing; and high-level, ongoing support. In return, the vendors have a new type of customer who values public benefits, such as systemwide quality improvement and efficiency, and demands scalability and standardization over customized solutions. To succeed, the work required to implement and maintain EHRs in each incremental practice must be lowered dramatically. Projects must take advantage of economies of scale while continuing to meet the diversity and particularity of practice needs.
This requires standardization of implementation processes, software, data models, interfaces, and training. Each step must be made "as simple as possible, but not simpler." We recognize that standardization comes at a cost; one size does not fit all. At the very least there must be a menu of (standardized) options from which practices can choose. However, practices may need help to realize the advantages of a standardized approach and identify workflow changes that can substitute for software customization. These may be labor-intensive "workarounds," but in many cases, they are simply different ways of doing business.
Ideally, software applications and data models can be standardized while permitting practices to configure the software to their particular needs. In addition, communities may want to work together to develop and maintain clinical content (such as templates, order sets, forms, reports, and indicators). Retaining both standard data models and community/practice configurations (for example, after software upgrades) is a significant but surmountable technical challenge.
HIE: a focus on functional interoperability. To achieve effective use of EHRs, extension projects must assure independent practices (including solo practitioners) that information will remain easily accessible. This will require a degree of "data liquidity" formerly available only within integrated delivery networks.
Despite long-standing requirements by the Health Insurance Portability and Accountability Act (HIPAA) and standards for insurance eligibility, electronic remittance advice, claim status, and other administrative transactions, many insurers still do not provide electronic EHR interfaces, implement standards differently, or omit important information (such as "primary care provider of record"). This requires building many custom interfaces or paying additional monthly fees to "clearinghouses" (intermediaries who process payments for multiple health plans).
Establishing electronic interfaces from commercial laboratories to small practices is difficult, and electronic ordering of lab tests is also a challenge. Market forces appear to be working against interoperability. Commercial laboratories have many disincentives to establishing electronic lab interfaces with small practices: EHRs may lack the decision support found in lab ordering portals (for specimen handling, appropriate diagnostic codes, and exclusive insurer arrangements); laboratories may be required to pay EHR vendors thousands of dollars for every interface; and according to the Commercial Laboratory Improvement Amendments (CLIA), laboratories are responsible for the delivery and formatting of results to ordering physicians, which means that each interface must be individually tested and validated. New technical approaches (such as a community "hub" for maintaining lab compendia and for routing orders and results) may be required to make EHR interfaces more economical for commercial laboratories. In addition, payment incentives or mandates as well as regulatory updates (for example, CLIA regulations that consider the delivery of electronic results through standardized interfaces) may also be necessary.
Despite recent progress, electronic prescribing still offers few advantages over printed or faxed prescriptions. Selecting pharmacies can be slow, pharmacy lists can be inaccurate, and rerouting prescriptions to a different pharmacy can add work. Failed electronic transmissions may not be clearly visible to the provider. Even within technically enabled pharmacies, individual pharmacists may have difficulty locating prescriptions or initiating refill requests. Furthermore, electronic prescribing incentives, as currently designed, do not encourage informed prescribing. Physicians rarely use medication histories to monitor adherence or check for interactions with drugs prescribed by other physicians. Although widely available for commercially insured patients, fill histories are typically absent for those with recent insurer changes, no insurance, or public insurance. Data flows between EHRs, pharmacies, and benefit managers do not facilitate matching of EHR orders to fill status. Nor do EHRs encourage or optimize use of this information for comparison and reconciliation of internally generated and external medication lists.
Meanwhile, some HIE organizations have begun to meet some needs for functional interoperability and messaging. They are assuming some increased risk and liability but may be choosing the most direct path toward sustainability and a more dependable business model.7
Community projects are necessarily stakeholders in the development and improvement of functional interoperability. We represent the interests of our community practices by advocating for better and more consistently applied standards and for policy change, encouraging collaboration between vendors, and piloting innovative technological solutions.
Working in the public interest: keep an eye on the ultimate goal. Until now, our focus was on the lessons learned for successful communitywide implementation that is on budget and adheres to set time limits. To achieve this, community projects must meet medical practices’ business needs, paying close attention to issues that affect their bottom line (scheduling, eligibility, billing) and workflow needs. However, we must be aware that our ultimate goal is not EHR implementation. Community projects, often supported by public funds, are concerned with a public good: improved public health, quality of care, health system efficiency or equity, or continuity of care. This orientation must permeate all aspects of the project, including EHR selection, customization, practice readiness, training, support after the project goes "live," and information flows. We must ensure that EHRs are used in the service of these goals and develop evaluation systems to monitor that outcome. Although widespread EHR implementation may be a precondition for achieving our goals, it is rarely sufficient.
This project was harder than anticipated for everyone involved. To be successful, our projects required high-level executive leadership and millions of dollars as well as a cadre of extraordinary staff members; robust project management structures and processes; and the liberal application of patience, diligence, and innovation. We do not yet know if our projects have improved the quality of care in our communities, but we have succeeded at helping a large number of independent practices of all sizes adopt comprehensive ambulatory EHRs within a relatively short time. The superstructure of communitywide project management, vendor relations, practice redesign, technical support, and quality improvement is as essential to this success as are the financial subsidies we provided. Considering the extremely low rate of adoption of ambulatory EHRs nationwide, particularly among small practices, this experience is noteworthy. Perhaps more important, projects like this one have the size and sophistication to work collaboratively with vendors and communities to create scalable solutions that may benefit practices throughout the nation. Widespread EHR adoption is difficult to accomplish with community projects, but it may be impossible without them.
Editor's Notes Farzad Mostashari (email@example.com ) is assistant commissioner, Primary Care Information Project, at the New York City Department of Health and Mental Hygiene. Micky Tripathi is president and chief executive officer of the Massachusetts eHealth Collaborative in Waltham. Mat Kendall is director of operations, Primary Care Information Project.
The development of the Primary Care Information Project was made possible in part by Grant no. 1 POI CD000275-01 from the Centers for Disease Control and Prevention, to the New York City Center of Excellence on Public Health Informatics. Farzad Mostashari and Mat Kendall gratefully acknowledge the inspired executive leadership of New York Mayor Michael Bloomberg and Commissioner Thomas Frieden and the editorial contributions of Sarah Shih, Remle Stubbs-Dame, and Thomas Cannell. Micky Tripathi recognizes Blue Cross Blue Shield of Massachusetts, the Massachusetts Medical Society, and Partners Healthcare for generous financial and in-kind support, as well as the spirited participation of the Massachusetts eHealth Collaborative board of directors and members of steering committees of the pilot communities. All authors express their deep gratitude and appreciation to staff, vendors, and practice partners, whose daily efforts were extraordinary.
C.M. DesRoches, et al., "Electronic Health Records in Ambulatory Care—A National Survey of Physicians," New England Journal of Medicine 359, no. 1 (2008): 50–60.[Abstract/Free Full Text] See, for example, Oregon Community Health Information Network, "History of OCHIN," http://www.ochin.org/historyofochin.htm (accessed 15 September 2008); Community Clinics Initiative, "California Networks for Electronic Record Adoption," http://www.communityclinics.org/section/cnea (accessed 15 September 2008); Electronic Health Record of Rhode Island, "About EHRRI," http://www.ehrri.com/whoweare_EHRRI.html (accessed 15 September 2008); and L. Landro, "Electronic Medical Records Are Taking Root Locally," Wall Street Journal, 22 September 2004. Massachusetts Health Quality Partners, "About Us," http://www.mhqp.org/aboutus/AboutUs.asp?nav=020000 (accessed 22 December 2008). The Primary Care Information Project received $11 million from New York State; $5 million from various federal grants, including a CDC Center of Excellence in Public Health Informatics grant; $7 million from the New York City Council; $3.5 million from private foundations; and $2.2 million from its partner practices. T.R. Frieden and F. Mostashari, "Health Care as If Health Mattered," Journal of the American Medical Association 299, no. 8 (2008): 950–952.[Free Full Text] The fictional vignettes are available at http://content.healthaffairs.org/cgi/content/full/28/2/345/DC1. J.M. Grossman, K.L. Kushner, and E.A. November, "Creating Sustainable Local Health Information Exchanges: Can Barriers to Stakeholder Participation Be Overcome?" Research Brief no. 2, February 2008, http://www.hschange.org/CONTENT/970 (accessed 23 December 2008).
Extraído da BusinessWeek - 19/12/2008 Autor: William A. Yasnoff, M.D., PhD
The current worldwide financial crisis is transforming the problem of rising U.S. health-care costs into a dire threat to our entire economy, making health-care reform an increasingly urgent priority. Any potential approach to restructuring health care must include universal electronic medical records so that both patient care and policy decisions are fully informed. In his weekly address to the nation on Dec. 6, President-elect Barack Obama made a commitment to this goal as part of his economic recovery plan. But what exactly needs to be done to achieve this?
Today, each person's medical records are scattered among all the places where care has been given—leaving no one with a complete copy. Amazingly, no health-care institutions are responsible for ensuring that complete records are available for each person when care is needed. As the President-elect stated, both the quality and safety of health care could be greatly improved if complete electronic medical records were immediately available to physicians. Efficiency would also increase through, for example, the elimination of unnecessary duplicate tests and imaging procedures. Of course, any system of electronic medical records requires stringent privacy protections to prevent unauthorized access or use.
Health record banks can address our health information needs by providing each person with an electronic "account" where copies of all their medical records could be deposited, stored, and retrieved. A health record bank account would operate much like today's familiar checking account. But instead of depositing money, your medical providers would deposit copies of your new records after each care episode (which they must do at your request under the Health Insurance Portability & Accountability Act, or HIPAA).
Just as you control the funds in your checking account, you would retain sole authority over access to any portion of your medical records in a health record bank. Normally, you would make the complete records available to your own doctors and to health-care personnel treating you in an emergency. You would have access to your records yourself (including the ability to add information if you wished) and would be able to see exactly who else has accessed your records and when. With your permission, your information could be aggregated with others' data into anonymized reports for public health officials, medical researchers, and policymakers.
Health record banks would be required to protect your privacy by guaranteeing that you fully control who sees any portion of your records, and to safeguard your information using the same computer security techniques applied today to protect classified military information. There would also be regular independent privacy and security audits (analogous to auditing requirements for financial banks). Health record banks would be privately financed, owned, and operated, and governed either by community nonprofits or via regulation. Multiple competitive health record banks are entirely feasible to provide choices for consumers.
A health record bank account would cost no more than $1 per month—and the health-care savings from the availability of the information would be many times that amount! Some employers may elect to cover this cost as part of their health plan, particularly for beneficiaries with chronic diseases where improvements in quality of care and cost savings from having complete electronic medical records would be even more substantial and immediate.
Health-Care Cost Savings
Of course, successful health record bank operation depends on all medical records being electronic. Today, however, fewer than 20% of physicians use electronic medical record systems in their offices, primarily because most of the financial benefits of these systems accrue to others. Financial incentives for electronic medical record systems from health record banks could promote universal adoption and solve this problem, thereby achieving the President-elect's goal.
The Obama Administration's strategy for achieving universal electronic medical records should include policies that facilitate and encourage health record bank development including: (1) statutory privacy protection of medical information; (2) requiring physicians to supply a no-cost electronic copy of newly generated medical information at the time of service (which could be directed to a health record bank account); and (3) making health record bank account fees (up to $12 per year) a covered benefit for all federal health beneficiaries (federal employees, Medicare, Medicaid, Defense Dept., Veterans Administration, Indian Health Service, etc.).
This latter policy would only create expenditures when a health record bank account is actually opened and used—and having the account would ensure health-care savings of at least 10 times the covered cost. Taking these actions to develop a system of health record banks represents an inexpensive yet critical first step in health-care reform that could simultaneously save money, save lives, and protect individual privacy.
As I commented on the story, "Wal-Mart Launches E-Health Program," HIPAA's privacy rule actually allows disclosure of private medical information without consent to anyone for "treatment, payment, or health-care operations" (TPO), thereby eliminating privacy. While this HIPAA provision at first appears to be quite reasonable, the decision about whether a specific disclosure is for TPO is made solely by the entity that holds the information with no notice to the patient, no possibility for review or appeal, and no requirement for keeping records of the disclosures. The current system is anticonsumer—and certainly not in the spirit of President-elect Obama's goals to improve the U.S. health-care system.
William A. Yasnoff, M.D., PhD, is an Arlington (Va.)-based physician and computer scientist. He is currently managing partner of National Health Information Infrastructure (NHII) Advisors, a health information technology consulting firm. He previously served as senior advisor, NHII, U.S. Health & Human Services Dept. from 2002-2004.
Are international standards the most important factor in healthcare interoperability? A reader poll ahead of the Healthcare Interoperability conference in Birmingham decided that they were. But what would expert debaters and their audience think on the day? Fiona Barr reports.
Are international standards the key to long-lasting success in healthcare interoperability - or are they sometimes doing more harm than good? That, essentially, was the question posed by those speaking in the debate at E-Health Insider’s Healthcare Interoperability conference in Birmingham.
For the motion
Paul Woolman, ehealth information architect in the ehealth directorate of the Scottish Government, proposed the motion that: “This House believes that international standards are the most important factor in achieving interoperability in healthcare.”
He argued that interoperability is not only about achieving the technical transfer of data, but also about ensuring that the clinical meaning is understood. To get that to work, successful international standards are essential, he said.
“You can do things with local solutions but to do things that last for a long time you need international standards,” he added. His view was backed up by Philip Scott, a board member of HL7 and head of IT projects and development for Portsmouth Hospitals NHS Trust.
Scott argued that standards were not a bar to life in the real world and standards such as those used in debit cards were proof that international standards could work. “Standards have to be international because vendors are operating in a global market,” he said.
The case against the motion was put forward by Martin Strange, head of health IT at Lloyds Pharmacy. Strange said he believed that some standards were “the greatest impediment” to interoperability and that open, national standards were much more important. He said these could retain flexibility while delivering functionality and: “We need that flexibility.”
Strange was backed by Ian Herbert, an independent health informatician and vice-chair of the British Computer Society’s Health Informatics Forum. Herbert argued that international standards are not developed in a coherent manner and not always developed by the most appropriate people to do the job. He also said features that were relevant to the US were not always relevant in the UK - and vice versa – while international standards were difficult to change and complex to maintain.
“What actually matters is reliable and consistent use of standards, and international standards don’t make this any easier,” he said.
Open for debate
The four debaters were questioned about the commercial impact of different standards on suppliers who want to market their software worldwide. Woolman said there was evidence from the medical devices market of big companies being willing to work together on standards to try and defer some of the costs - which could then benefit smaller suppliers.
But Herbert argued that while international companies liked to work to international standards this could also be a bar to innovation among smaller companies. He said that, for example, the cost of getting products tested by NHS Connecting for Health, the agency that runs the National Programme for IT in the NHS, could be prohibitive. “Some of these complex standards are actually doing some harm as well as good,” he said.
Dr Mary Hawking, a GP in Bedfordshire, asked whether international standards should be introduced for information itself, given that healthcare interoperability was all about moving patient data around. Scott responded that clinical practice differed across the globe and that achievement would have to be limited to some sort of summary, highlighting the proposals for a European health record summary.
Others in the audience suggested that introducing standards for clinical content was critical before anything else was tackled. The newly-published standards developed by the Royal College of Physicians were welcomed as a good first step. “Unless we address the clinical content we have nothing to convey,” one doctor said.
Summing up for those supporting the motion, Woolman said national standards were never going to be enough. “Medicine is an international business. Companies work internationally. They want to use international standards. International standards have to be used in the long term,” he said. However, the motion was lost by just one vote.
My patient probably would have rather been anywhere else. He and his wife were in my office to discuss his erectile dysfunction for the first time. He looked uncomfortable. For a guy who doesn't go to the doctor much, a medical office can seem as foreign and intimidating as the dark side of the moon.
His exam was normal, but he needed to quit smoking. Would it have been easier for you to fill out a questionnaire on the Internet and skip the office visit? I asked. "You bet," he replied.
The way I see it, he didn't really need to come in at all. He needed a risk assessment for heart disease, a prescription for medication, counseling and help with stopping smoking. The results would have been the same online or in person. How would you feel about "visiting" your doctor online for routine medical issues such as allergies or sinus infections, or potentially embarrassing ones like erectile dysfunction? DiscussThe average American's health-care experience is fraught with high cost, poor service and uncertain quality. But the prudent practice of medicine online would improve health care on all three counts.
Patients want access to safe, reliable medical care on the Internet, just like banking, shopping or booking a flight. Eighty percent of the public want doctors to use email to communicate with patients, but only 9% of physicians actually do that even occasionally.
I think 20% of my routine office visits could be handled safely and less expensively over the Internet. There is nothing magical about the four office walls that make face-to-face visits superior. Demanding an in-person visit for every little thing is based on tradition and consensus opinion -- not science.
Doctors trot out excuses about why they don't use the Internet as a tool for working with patients. I think doctors' big fear is that the online discussions with patients will eat up time, with little or no extra payment for the service.
A big impediment is that in most states it is illegal to prescribe drugs for a patient based on an online evaluation. That seems strange to me because physicians have been prescribing medicines by telephone for simple things without the safety net the computer provides.
Of course, there have been cases of inappropriate prescribing of narcotic medications in my home state, Illinois, and others. And regulators put the clamps on even legitimate use of Internet medicine without a face-to-face physical exam.
The medical establishment has been reluctant to embrace online medicine. Indeed, medical societies and the Federation of State Medical Boards have taken a very aggressive position against Internet prescribing in the name of patient safety. In their world, only in-person visits are thought to be safe.
Are the boards of medical examiners' policies really protecting patient safety or only mandating face-to-face office visits as economic protection for doctors, I wonder.
If I tried to prescribe ED drugs today based on an Internet questionnaire and email correspondence, the state medical board could take my license away and fine me thousands of dollars for every patient I treated.
I have no desire to be a Viagra prescription mill. I bring up the medicine because ED care over the Internet is probably the most studied of online options.
There are broader applications for Internet treatment beyond ED. And to be absolutely clear, there's no evidence that only face-to-face office visits are safe, effective and high-quality.
Traditionalists in medicine may be afraid to learn how good Internet medicine can be. One of the first substantial studies of Internet medicine was conducted by the University of Utah and published this month in the journal Mayo Clinic Proceedings. The researchers compared traditional office treatment of erectile dysfunction versus Internet practice.
The patients treated online had no face-to-face exam. The traditional doctors had the benefit of a computerized record system but they still lost out to the Internet doctors, who took a more thorough history and provided more counseling with the aide of a standardized Internet-based system. Internet practice for ED was equal to traditional office practice or safer in all areas studied.
As a small-town doctor who still makes house calls, the prospect of an Internet practice is quite a departure from business as usual. As the Internet-savvy population ages and the number of primary care doctors dwindles, the demand for safe online medicine will grow.
Until the regulators come around to the advantages of Internet medicine, patients will continue to miss work over minor ailments and I'll keep seeing them at the office.
21/08/2008 - Extraído do NATIONAL CENTER FOR POLICY ANALYSIS
The use of information technology in diagnosing, treating and monitoring patients — known as telemedicine — is adding a new dimension to modern health care. Entrepreneurs are using the telephone, the Internet and personal computers for innovative solutions to traditional problems of health care delivery. These advances are not only making care more accessible and convenient, they are also raising quality and containing medical costs.
Problems with the Traditional System. Several factors contribute to the costly and inefficient delivery of traditional health care services.
Patients find doctors harder to see. Seeing a doctor is becoming increasingly difficult. According to a study of medical care access between 1997 and 2001 [see Figure I]: - One-third of patients reported problems seeing their primary care physician. - Nearly one-quarter reported problems taking time from work to see a physician. - Twelve percent reported their doctor was hard to reach by phone or too far away.
Patients also have trouble contacting physicians outside the traditional office visit. Although lawyers and other professionals routinely consult with their clients by telephone and by e-mail, very few doctors currently consult by telephone and less than one-in-four communicates with patients electronically.
Patients overuse emergency rooms. In a given year, 55 percent of the 114 million visits to hospital emergency rooms are for nonemergencies. A 2006 survey of California hospitals found that nearly half of ER patients thought they could have resolved their medical problem with a visit to their doctor, but were unable to obtain timely access to care. Moreover: - Seventy-one percent of Medicaid enrollees and 63 percent of privately insured visitors said seeking Emergency Room care was more convenient than seeking care from their - More than half of both groups experienced symptoms after normal office hours or on a weekend, when their physician was not available. - Nearly half of patients who visited an ER said they could not get a timely doctor’s appointment [see Figure II].
Patients aren’t adequately informed. The amount of information physicians need to convey to patients during an office visit has increased over the years, but the average time they spend with individual patients has remained roughly the same. The proportion of physicians saying they do not have enough time to spend with patients rose nearly 24 percent between 1997 and 2001, from 28 percent to 34 percent. Moreover, according to the Journal of the American Medical Association, patients usually want more information about their medical condition than they receive from their doctors - and with good reason: - During a 20-minute office visit, physicians spend less than one minute planning treatment, on average. - Doctors discuss options and help patients arrive at a treatment based on their preferences during fewer than one in 10 office visits. - About half the time, doctors fail to ask patients whether they have questions.
Benefits of Telemedicine. Information technology has the potential to restructure medical care in ways that can solve many of these access problems, while reducing costs and improving the quality of care. Already, entrepreneurial providers are creating services outside the third-party payment system that allow patients to pay directly for access to physicians or nurses electronically or by telephone.
Case Study: Convenient care by TelaDoc. TelaDoc Medical Services is a phone-based medical consultation service that links physicians, patients and health plans across the country. The service is not intended to replace primary care providers, but it allows patients who are away from home to obtain less expensive and time-consuming treatment by contacting a local physician, rather than visiting an emergency room or expensive urgent care center.
An individual enrollee pays $35 for each consultation (compared to an emergency room visit costing an average of $383), and the service is available around the clock. For efficiency, medical records are digitized and placed online, allowing medical personnel access from anywhere in the country. TelaDoc guarantees a physician will return the call within three hours or the consultation is free, but customer surveys show that most calls are returned within 30 to 40 minutes. Moreover: - A physician returns a patient’s phone call within 30 minutes (or less) 50 percent of the time. - Seventy-five percent of patient calls are returned within one hour. - Eighty-eight percent of those who used the service reported they saved time and money compared to a traditional office visit or a trip to the emergency room.
A recent analysis by the consulting firm Mercer found that 97 percent of users rated the service good or outstanding, and 98 percent said they would use it again.
More Benefits of Telemedicine. Telemedicine can improve adherence to protocols and increase the convenience of treatment for patients with chronic ailments. For instance, patients can use an electronic device to monitor their vital signs at home and transmit the data via computer modem to self-report their health status to medical staff. A study of patients with congestive heart failure found that those who used remote monitoring required rehospitalization only half as frequently as those who depended on traditional office visits.
Additionally, transmitting data via the Internet allows U.S. health care providers to collaborate with qualified, low-cost providers in other countries who perform labor-intensive tasks that do not require the physical presence of a physician, such as interpreting ultrasounds, CT scans and MRIs. Increasingly, information technology will make distance irrelevant and medical personnel will be able to provide medical services regardless of their location.
Obstacles to Wider Use of Telemedicine. An antiquated third-party payment system is the primary obstacle to the growth of telemedicine. Because 87 percent of medical costs are paid by someone other than the patient (such as insurers, employers or government), providers have little incentive to create innovative services that benefit patients directly. Additionally, state laws and regulations prevent physicians licensed in one state from practicing in other states. This impediment keeps doctors from providing crucial medical services, such as writing prescriptions or completing follow-up consultations remotely, to patients who have left the state. Similar regulations keep foreign doctors from providing telemedicine services. Telemedicine can improve the quality and increase the efficiency of patient care, but these barriers must be lowered in order to realize its full potential. * Devon Herrick is a senior fellow at the National Center for Policy Analysis.
Connecting doctors with patients via video is not new - but is now the time for it finally to take off?
When Anne Urquhart of Aberdeen arrived in hospital with an injured toe last week, she was surprised when the doctor asked if she could examine her via a video screen. Aberdeen Royal Infirmary is conducting the NHS's latest experiment in telemedicine - the decades-old idea of diagnosing and treating medical conditions via electronic links rather than face-to-face.
The trial's backers, who include the networking company Cisco, say a new set of technologies called telepresence, coupled with new pressures on the NHS, could make the experience commonplace.
Videocall me tomorrow
It's an old futurological dream. Telemedicine made its public debut in 1924, when Radio News magazine illustrated a doctor examining his patient on a radio set equipped with a screen. In the 1950s, the University of Nebraska began experiments on medical consultations over CCTV; in the 1960s, Nasa sponsored telemedicine for Native American communities as well as astronauts to demonstrate the spinoff benefits of space travel.
In the 1990s, tumbling hardware prices and digital communications generated a wave of interest, especially in countries with scattered populations such as Norway. However, unless you count the speech-only NHS Direct service (NHS 24 in Scotland), telemedicine has found few uses in the UK. Even when doctors accept the technology, in a small country with a comprehensive health service it usually makes more sense to transport the patient to a doctor than to set up a video link.
For obvious reasons, the main centres of NHS interest are in Wales and Scotland, where telemedicine has proved useful in linking patients in remote areas to specialists such as dermatologists. What's new about the Aberdeen trial is that it tests the use of telemedicine for a whole range of GP and A&E consultations.
Gordon Peterkin, director of the Scottish Centre for Telehealth in Aberdeen, says that a new swathe of pressures on the NHS, from new contracts for doctors to the green agenda, mean telemedicine's time has come.
The enabling technology is telepresence, a video conferencing system which presents a life-size high-definition image of the other party as if they were sitting just across the table. The patient's booth includes medical devices - such as a stethoscope, blood-pressure cuff and thermometer - to transmit essential information to the doctor. Crucially, the whole setup works on a standard network, which means it can be deployed everywhere there is broadband: it needs about 3.5 megabits per second.
Cisco is promoting the package globally under the brand name HealthPresence. It provided hardware for the Aberdeen trial, and is funding half of the £30,000 evaluation. (It also paid for the Guardian, and three other publications, to attend a press demonstration last week.)
The experience is uncannily close to life - when talking to a doctor through the system I found myself reacting automatically to her body language, edging back when she leaned too close. Real patients seem to agree. "It was just like a normal consultation," says Urquhart.
However, a large number of questions need to be resolved before teleconsultations with family doctors become routine. The immediate purpose of the Aberdeen trial is to check whether teleconsultations are as effective as face-to-face ones. Despite the long history of such pilots, Peterkin says there is a dearth of hard data of the kind that would be required for other medical innovations.
At Aberdeen, patients who volunteer for teleconsultations in the hospital (the doctor is just down the corridor) also receive face-to-face examinations. About 30 patients have been through the trial and so far there have been no differences in diagnosis, according to James Ferguson, an A&E consultant. The trial will need about 300 patients to get a statistically significant sample.
The next stage will be to move the patient booth to a "remote safe site", probably a community hospital, where hands-on medical help is available. If that works, the booth could go almost anywhere. "We might put it in a hotel, or a police station," Peterkin says. The booths could be shared with other public services, such as social security benefits. Self-service booths are unlikely, however - the plan is that a trained attendant will help patients with medical devices and point a handheld camera where needed.
Even if the trials succeed, creating a business case for the service may be difficult. Cisco won't say how much the hardware will cost. "We haven't priced the booth," says Nick Augostinos, the company's healthcare solutions director. Among other things, the cost will depend on the level of medical equipment and the state of existing broadband networks.
Except in special cases such as prisons and offshore oil installations, sustainability has always been telemedicine's big difficulty. Setting up a sponsored pilot is one thing, running an ongoing service is quite another. The lesson of 50 years of telemedicine is that, even if the technology has finally come of age, that is only one part of a much larger jigsaw.
Some experts say patients shouldn't have to rely on files like these to store their health information.
By Linda Stahl, The (Louisville) Courier-Journal
While you can retrieve cash from your bank account anywhere in the world and maintain your bank records online, Americans seldom maintain their health records by using software, hardware and Internet connections.
This is because the medical system has lagged in using information technology. Only an estimated 10% to 20% of U.S. hospitals and physician offices maintain fully computerized patient records.
But with many of us taking a greater interest in our health care — partly by researching health information online — some experts believe the time is ripe for patients to create their own electronic personal health record, also called a PHR.
Advocates say it's a new way to take your health in your own hands.
A PHR is a comprehensive record that you own, control and maintain over time. You decide when to share its contents — in response to a doctor's inquiry or because you think there is something more a doctor needs to know about your health history.
Your personal health record should be electronic, easily portable, private and secure.
The contents will include such essentials as your current medications and dosages, health-insurance info, living will, immunizations with dates, allergies, important recent medical test results, surgeries, family medical-history highlights and more.
Proponents say a personal health record can help health providers work more quickly, avoid errors and duplication of tests, and save lives.
"I'm a new mother with a 6-month-old," says Wendy Angst, general manager of CapMed, a Newtown, Pa., company that sells personal health record tools, including a CD-ROM and USB flash drive. "I created a USB for my daughter and started entering information when I was pregnant with her. It has information on all her immunizations and monthly doctor visits."
When you create your own personal health record, "you have the information and you become your own advocate for making sure the right information is available to the right people at the right time," Angst says.
If the idea of creating a personal health record seems daunting, "start with today," Angst suggests. "If you have an active chronic condition (like diabetes or asthma), just get your records for the last six to 12 months. You can constantly amend your data."
More than two dozen tools and services exist to build a personal health record. Some are free; others charge. AARP studied 24 such products and found the most expensive cost $500, but many cost much less.
Dr. Edward Fotsch of San Francisco was an emergency-room physician for a decade before switching to a company that creates a Web-based personal health record tool.
"Seventy percent of our users are women storing information about kids, spouses, aging parents and themselves," says Fotsch, who runs Medem Inc., on online business that links the needs of patients and doctors through the Web at iHealthRecord.com.
Let's say you see an allergist, a gynecologist, an internist, a dermatologist, a dentist and a podiatrist in the course of a year. For your sake, your doctors should be aware of the others' treatments and tests.
Access to your personal health record can help in a medical emergency, even when traveling internationally.
The Institute of Medicine reported in July that 1.5 million adverse drug events occur annually, many because of interactions of drugs prescribed by different doctors. The institute concluded that patients "should learn to keep careful records of all the medications they are taking."
At the very least, services are duplicated and costs are driven up in the fragmented U.S. health care system.
Nationally, President Bush has called for the development of electronic patient records by 2014.
In the meantime, advocates say consumers should get ahead of the government efforts, partly because there is no reason to wait and partly because the very act of creating their own health history will make people more responsible for their health.
Personal health record tools and services also can also prompt patients to make follow-up appointments as well as issue warnings.
Fotsch says iHealthRecord.com sends an e-mail the same day that a drug has been recalled by the U.S. Food and Drug Administration. That could immediately alert a family caregiver that an elderly parent's medication should be stopped.
Fotsch's Web-based service is free to patients, but physicians pay a $35 monthly fee to participate. He says participation by your physician makes the program interactive and enhances communication.
1. Contact your doctors and/or medical-records offices of places where you received treatment. Find out if your doctor has a plan for you to use. Find out if information is in an electronic format you can access, or request paper copies if needed. Get guidance on which records you need.
2. Ask for "authorization for the release-of-information" forms. You may be charged for copying and mailing and may have to wait up to 60 days for your information.
3. Put everything in a file folder or binder since it's unlikely everything will be available electronically. Don't forget to include information only you can provide, such as family medical history, over-the-counter drugs, exercise and diet habits.
4. Research tools and services. Some are free. You may want to store your information on a website, put it on a CD or USB key chain. One place to start looking is www.myphr.com. At the bottom of the home page, click on "research PHR tools and services."
5. Take your personal health record with you to doctor appointments. Make sure a trusted party has access to it if you are incapacitated. Keep it up to date.
6. Create a card with vital information, such as medications and allergies and carry it with you.
7. Remember to protect and maintain your personal health record and share it only with those you want to see it.
WHAT TO INCLUDE
A personal health record should contain the following information:
• Personal ID: name, birth date, Social Security number.
Extraído da Healthcare IT News e escrito por Diana Manos, Senior Editor, em 15/02/2007.
Healthcare information technology could help to reduce healthcare nding up to 50 percent, but not until a decade after widespread adoption, said former U.S. national health IT coordinator David Brailer in an interview announced Thursday in Health Affairs.
In the Health Affairs interview, Brailer said that even if President Bush’s goal of acquiring EHRs for every American by 2014 were achieved, it would not increase productivity in healthcare immediately. “We’ll have a decade of HIT implementation before a decade of major yield.
It’s not until the second decade that users say, ‘Now that we have the tools in place, let’s use them to redesign our fundamental processes’.”
Brailer told his interviewer – Leapfrog Group cofounder Arnold Milstein – that healthcare IT could contain healthcare spending only if:
• providers give control of clinical information to patients
• there is universal public availability of provider performance comparisons
• health policy is moved from its current “no-man's land” between government and market control
Brailer said that one-third of providers will not be able to adopt electronic health records without policy interventions.
“We are now in the period of adoption by the willing – large hospitals or large physician groups – organizations that have been planning this for some time or that have the native capacity to take on such a complicated project,” Brailer said. But “small doctors’ offices, one- or two-person practices, safety-net clinics, and rural and underserved areas are not there yet.”
Brailer pointed out that, according to studies of other U.S. industries that have undergone automation, such as manufacturing, retail, food preparation, insurance, financial services, “it takes about a decade after the substantial majority of the players are automated for full benefit to be gleaned.”
Brailer said he expects healthcare to follow suit.
Brailer also said that major productivity gains couldn’t be achieved until all the stakeholders are invested in healthcare IT. “A hospital or physician can’t reap the full benefits of communicating electronically or of passing information back and forth, or of eliminating middle suppliers, until the other has also done so,” Brailer said.
Extraído da Healthcare IT News e escrito por Diana Manos, Senior Editor, em 15/02/2007
Extraído da Publicação Times Argus - 24 de Dezembro de 2006
By Mel Huff Staff Writer
Anyone who has had an encounter with a hospital knows the drill. You register. You fill out a questionnaire attached to a clipboard asking you to list all the medications you are taking. A nurse then asks the same questions. Later, two or three nurses in other departments take down the information and then a doctor reviews it with you.
By the end of February, Vermonters who use the Rutland or St. Johnsbury hospitals will be able to eliminate that drill by taking advantage of new information-sharing capabilities between distant computers. A health information exchange system being implemented by Vermont Information Technology Leaders will allow emergency room doctors at Rutland Regional Medical Center and Northeastern Vermont Regional Hospital to access patients' prescription records – with their permission – and within seconds get an accurate printout of their patients' medication history. Eventually, the medication history service will be available in emergency departments statewide.
VITL – the acronym for Vermont Information Technology Leaders is pronounced "vital" – was created in 2005 with a $1.4 million grant from the Vermont Legislature to
develop a technology plan for the exchange of health information among doctors, hospitals, pharmacists and insurers. Its first customer was the Vermont Department of Health, which contracted with VITL to develop the software for the state's chronic care initiative, the Blueprint for Health.
The medication history service will be the first project that VITL implements. It was picked as the starting point, VITL president Greg Farnham said, because when the organization surveyed doctors about where in their practices they saw the most acute lack of information, they identified getting comprehensive medication histories as their top difficulty.
When a patient gives a doctor permission to access his/her records, the doctor will be able to send a query through a computer and get a list of all the medications that patient has paid for, including some over-the-counter drugs. (The system won't return the names of free samples that doctors have provided.)
VITL will serve as a hub, collecting prescription data from various pharmacy benefit managers, known as PBMs, which administer prescription drug plans for insurance companies. The benefit managers, which are connected to wide networks of retail and mail-order pharmacies, store patients' medication history data on their computers. VITL will bring information from the pharmacy benefit managers to the hospitals and make it accessible.
The information will include dosages, the dates the prescriptions were picked up and the number of refills. The system will cut down on the time that doctors and nurses spend taking medication histories and save the health care system money, as well as relieve patients from trying to remember the names and dosages of all their prescriptions. Some patients take so many medications that rather than trying to remember them all, they bring the bottles to appointments in a brown paper bag.
Catherine Schneider, a nurse and the clinical leader in the emergency department of Rutland Regional Medical Center, said she thinks the medication history service will be beneficial.
It could help patients who have a primary care provider but might recently have seen another caregiver who prescribed a drug that is incompatible with one they are already taking. Both the patient and the doctors might be unaware of the problem until "we happen to catch it by seeing their medication list in whole," Schneider said.
Access to a comprehensive medication list will make it easy for doctors in the emergency department to avoid prescribing a drug that a patient is already taking as a maintenance medication. Patients "that are on a lot of different medicines … have a hard time keeping track," Schneider said. She added that they might not know the same drug was being prescribed if one doctor used the generic name and another used the brand name. Other patients who will benefit include "people with decreased levels of consciousness or altered mental status, whether that's from an injury or elderly dementia" or a drug overdose, she said.
"I think the patients will be happy to have it all there and not feel so responsible," Schneider declared. "For the most part we're talking about people I think it would be more of a safety net and a convenience for them than anything."
Extraído do "The New York Times" - Barbavy J. Feder - Setembro/2006
The communications system at her home bedside can’t cure Heather Huntoon. But it may be helping keep her alive.
Since the night 18 months ago when she woke up fearing she was having a heart attack, Mrs. Huntoon’s life has been dominated by a succession of heart, kidney and circulatory problems that have repeatedly landed her in the hospital.
“When you go through what I’ve been through, you have an overwhelming feeling that you can’t trust your body any longer,” said Mrs. Huntoon, who is 42 and lives near Wichita, Kan.
But Mrs. Huntoon does trust the lifesaving potential of an array of devices that let doctors monitor her condition remotely. Mrs. Huntoon’s setup is among the most sophisticated of the remote-monitoring systems now in use around the country to follow several hundred thousand patients.
The centerpiece of her system is an implanted device that regulates her heartbeat, delivers lifesaving shocks when necessary, and wirelessly communicates with her doctors via the Internet.
The same communications system is also linked to her blood-pressure monitor and a bedside electronic scale. By remotely watching data on her condition for signs of the next potentially life-threatening development, her doctors have occasionally been able to change her heart medications in time to let Mrs. Huntoon avoid yet another trip to the hospital.
A month ago, the system alerted her doctors that it might be time for her to be readmitted. Weight gains picked up by Mrs. Huntoon’s monitors led to a series of phone consultations in which she reported unusual dizziness and breathing problems. She was quickly sent to the hospital where a CAT scan revealed the onset of pneumonia. She was released a week later.
Medical device makers see patients like Mrs. Huntoon as harbingers of technology changes that will allow tens of millions of Americans with chronic problems like heart failure, diabetes and mental illness to have their conditions constantly monitored, remotely and virtually, as they go about their daily lives. The payoff for patients could be more effective use of drugs, fewer and shorter hospital stays, and longer stretches between routine visits to physicians’ offices.
“It’s about just-in-time medicine, instead of just-in-case,” said Dr. Adam Darkins, a care coordination expert at the Department of Veterans Affairs, which oversees the Veterans Health Administration.
The department is currently using relatively simple home monitoring devices to help manage the treatment of nearly 14,000 military veterans suffering from heart disease, depression, diabetes and post-traumatic stress disorder, Dr. Darkins said. It plans to expand to 21,000 patients by October.
The many companies betting on remote-monitoring medical technology include makers of implantable devices like Medtronic, instrument companies like Honeywell and Philips, and countless hardware and software companies ranging from start-ups to giants like Intel.
Business executives say that demographics and health care economics will give patients and doctors little choice but to adopt the technologies as they improve.
“The aging population and chronic diseases create an untenable drain on the health care delivery system,” said L. David Whitlinger, a health care electronics specialist at Intel, which sees the growing array of networked devices being developed for remote and automated medicine as a huge new market for its microchips.
“The hospital bed and waiting room of the future is your home,” Mr. Whitlinger said.
For every extreme case like Mrs. Huntoon’s, there are many more patients like Mason Bohana.
Mr. Bohana, an 82-year-old World War II veteran, has been able to move from living in a hospice under round-the-clock medical supervision to a Brooklyn studio apartment with the help of a relatively simple monitoring system from Health Buddy Networks.
The hand-held Health Buddy console, which plugs into his phone, delivers his blood pressure and weight readings to a Veterans Affairs nurse. It also prompts him to answer a series of qualitative questions about his lung and circulatory ailments, like whether his breathing is better or worse than the day before.
“This is so simple a 2-year-old could do it,” Mr. Bohana said.
Still, the industry’s vision of an electronic health care network that never sleeps is a long way from reality.
Even leading-edge systems like Mrs. Huntoon’s currently fail to provide a comprehensive picture of chronic diseases. She had to be hospitalized in July when a drop in potassium levels in her blood — something none of her devices track — destabilized her heart.
For many doctors, there is also a pragmatic financial concern about gathering and reviewing remote data because many insurers are providing little or no reimbursement for such work.
“There’s only so much time in a day you can devote to some of these things,” said Dr. Stephen T. Hustead, a doctor in Coon Rapids, Minn., who implants heart devices like Mrs. Huntoon’s.
So far, doctors say, there are no set standards for how frequently the available data must be checked. Many physicians currently rely on data collection services run by the device companies and independent monitoring services to warn them of anomalies that might require prompt attention. But doctors and their employees fear that plaintiffs’ lawyers will try to pin legal responsibility for recognizing warning signals on them, no matter who is collecting the data.
“You have to follow up on more things,” said Jennifer Gorham, one of the nurses working in Coon Rapids for Dr. Hustead and his partners at Metropolitan Cardiology Consultants. “If the device is programmed to look for it, you have to look for it.”
A main use of the data gathered by the newest devices is to reconstruct events that send patients to emergency rooms. In some cases involving heart implants, doctors get the data soon enough to reassure patients that their implant has restored normal heart function and there is no need for such a trip.
More often, the remotely monitored data is used to cut down on the need for routine checkups. Many of Dr. Hustead’s patients come to his office once or twice a year now instead of every three months. A Veterans Affairs study that followed 70 patients over three months found that remote monitoring of their heart implants freed up eight days of time doctors would otherwise have devoted to office visits.
Determining what the devices should be looking for, however, is a work in progress. In cardiac care, Medtronic and its rivals, including Boston Scientific and St. Jude Medical, have competing visions of how to provide the earliest reliable warning of fluid buildup in the lungs and other signs of imminent heart failure.
“Picking what you want to measure is a big part of what’s going on today,” said Mike Coyle, president of St. Jude’s cardiac rhythm management division.
The various companies are also competing to develop the best systems for getting data from the devices to patients and health care providers.
Mrs. Huntoon’s wireless system linking the implant, the scale and the blood pressure monitor is a product called Latitude. Guidant, which designed Latitude and began rolling it out late last year, was acquired by Boston Scientific in April.
For now, the only implantable heart device Latitude works with is Guidant’s top-of-the line Contak Renewal defibrillator. But Boston Scientific plans to expand the wireless communications features to its other defibrillators and pacemakers.
Boston Scientific is playing catchup to Medtronic, which has built up a data monitoring subsidiary called CareLink that can track data from 95 percent of its heart implant product line for doctors. Medtronic says that the network currently has 80,000 patients. Medtronic is now working on extending the CareLink concept to its diabetes monitors and insulin pumps.
One hot new area for the device industry is diabetes monitors that check blood sugar levels every five minutes through a tiny catheter inserted just under the skin of the abdomen. Medtronic received Food and Drug Administration approval to market its Guardian unit in August 2005. DexCom, a start-up company based in San Diego, began selling a similar device in the $6 billion diabetes care market in March. A third company, Abbott Laboratories, expects clearance to introduce its version by the end of this year.
The main function of the devices is to provide direct feedback to patients, letting them know when to take an insulin shot or alter their diet to avoid short-term symptoms of unbalanced blood sugar, like headaches and dizziness.
Such virtually continuous glucose monitors are more expensive, though less accurate, than the traditional finger-prick blood tests that millions of diabetics use, typically once or twice a day. The DexCom device, for instance, costs $800, plus $35 for sensors that are replaced every three days to limit the risk of infection.
Still, continuous monitoring is an important breakthrough, according to experts like Dr. Aaron Kowalski, scientific program director for the Juvenile Diabetes Research Foundation.
Keeping tabs on such data not only helps avoid short-term discomfort but also lowers the risks of long-term complications like stroke, blindness and heart disease. And the data collected on the devices, which can be downloaded to a personal computer, provides doctors with a much clearer picture of how well their patients are managing the disease.
“Knowing which way your glucose is going is really important in controlling diabetes,” said Dr. Kowalski, himself a diabetic. He described getting a DexCom device for himself in April as “almost a life-changing experience.”
Mrs. Huntoon says longer stretches between hospitalizations would be enough of a life change to make her happy. She says she hopes her doctors can add remote monitoring of her potassium levels to her routine, thus increasing the chances of stabilizing her unreliable heart.
The hospital employees know her so well they treat her like family, Mrs. Huntoon said. “But I don’t want to be a part of that anymore.”
Barbavy J. Feder - Setembro/2006 - "The New York Times" -
Extraído do Journal of Medical Internet Research - Julho/Setembr 2006
"Interest in an Online Smoking Cessation Program and Effective Recruitment Strategies: Results From Project Quit"E
Jennifer B McClure1, PhD; Sarah M Greene1, MPH; Cheryl Wiese1, MA; Karin E Johnson1, PhD; Gwen Alexander2, PhD; Victor Strecher1, PhD
1Group Health Cooperative Center for Health Studies, Seatle, WA, USA 2Henry Ford Health System, Detroit, MI, USA 3University of Michigan, Ann Arbor, MI, USA
Corresponding Author: Jennifer B McClure, PhD Center for Health Studies Group Health Cooperative 1730 Minor Ave, Suite 1600 Seattle, WA 98101 USA Phone: +1 206 287 2737 Fax: +1 206 287 2871 Email: McClure.J [at] GHC.org
ABSTRACTBackground: The Internet is a promising venue for delivering smoking cessation treatment, either as a stand-alone program or as an adjunct to pharmacotherapy. However, there is little data to indicate what percent of smokers are interested in receiving online smoking cessation services or how best to recruit smokers to Internet-based programs. Objective: Using a defined recruitment sample, this study aimed to identify the percentage of smokers who expressed interest in or enrolled in Project Quit, a tailored, online, cognitive-behavioral support program offered with adjunctive nicotine replacement therapy patches. In addition, we examined the effectiveness of several individual-level versus population-level recruitment strategies. Methods: Members from two large health care organizations in the United States were invited to participate in Project Quit. Recruitment efforts included proactive invitation letters mailed to 34533 likely smokers and reactive population-level study advertisements targeted to all health plan members (> 560000 adults, including an estimated 98000 smokers across both health care organizations). Results: An estimated 1.6% and 2.5% of adult smokers from each health care organization enrolled in Project Quit. Among likely smokers who received proactive study invitations, 7% visited the Project Quit website (n = 2260) and 4% (n = 1273) were eligible and enrolled. Response rates were similar across sites, despite using different sources to assemble the invitation mailing list. Proactive individual-level recruitment was more effective than other forms of recruitment, accounting for 69% of website visitors and 68% of enrollees. Conclusions: Smokers were interested in receiving online smoking cessation support, even though they had access to other forms of treatment through their health insurance. Uptake rates for this program were comparable to those seen when smokers are advised to quit and are referred to other forms of smoking cessation treatment. In this sample, proactive mailings were the best method for recruiting smokers to Project Quit.
(J Med Internet Res 2006;8(3):e14) doi:10.2196/jmir.8.3.e14
In recent years there has been an explosive growth of Internet users around the world and a corresponding upsurge in interest in using the Internet to deliver online public health interventions such as smoking cessation treatment. The potential advantages of Internet-based treatment are clear. From the users' perspective, online treatment programs are convenient; content can be accessed 24 hours a day, 7 days a week, 365 days a year. They also offer a greater level of anonymity than in-person or phone-based counseling, which users may find appealing. From a delivery perspective, Internet programs allow rapid, broad, and economical treatment dissemination. Programs can be highly tailored to mimic the individualization of one-to-one counseling, and the Internet has the potential to reach audiences who might not seek services otherwise due to issues of cost, accessibility, or stigma.
Whether Internet-based smoking cessation programs will be as effective as person-to-person counseling remains to be proven. To date, very few randomized efficacy trials have been conducted , but some promising preliminary data [2-4] suggest that well-designed online cessation programs could be effective public health interventions, particularly when combined with pharmacotherapy .
The ultimate impact of any public health intervention, however, is dependent on its reach, as well as its efficacy . Internet-based programs have the potential to reach millions of people, but potential reach is not actual reach. Actual reach requires access, acceptability, and utilization. While ongoing research seeks to establish the efficacy of online treatment, it is equally important to evaluate the acceptability and utilization of these programs in their target audiences. This assessment is hard to do because it requires a defined recruitment population and control over individuals' exposure to program advertisements, which is not possible in most research settings. No published studies to date, that we are aware of, have recruited smokers for Internet-based cessation treatment using a well-defined population that would allow accurate estimates of treatment uptake among smokers. Our best estimates come from surveys of Internet users. According to a recent Pew survey, 7% of adult US Internet users, approximately 8 million people, reported that they have searched online for information on how to quit smoking , but searching for information online is not the same as enrolling in an online cessation program. Joining a program requires a higher level of commitment and effort. This could partly explain why only 5-14% of smokers follow through with treatment referrals after being advised to quit [8-10] and less than 7% of smokers in the United States enroll in clinic-based cessation programs . Research is needed that will allow us to better understand the acceptability and reach of Internet-based smoking cessation treatment. Moreover, it is important to understand how best to advertise these programs to smokers to maximize treatment uptake.
In this paper we report on smokers' interest in Project Quit, an online, individually tailored, cognitive-behavioral support program with adjunctive nicotine replacement therapy (NRT) patches. Participants were recruited from two large health care organizations in the United States using a combination of individual-level and population-level recruitment strategies. Working within the health care organizations provided a defined patient population, making it possible to estimate interest in this program among likely smokers who were invited to participate and to evaluate the effectiveness of our recruitment strategies.
Project Quit is a collaborative study between the University of Michigan (UM), Group Health Cooperative (GHC), and the Henry Ford Health System (HFHS). The primary purpose of Project Quit is to evaluate the "active ingredients" of an individually tailored, online smoking cessation program. A secondary aim is to evaluate smokers' interest in Web-based cessation treatment and evaluate optimal strategies for promoting this service among smokers. Project Quit is being conducted in two independent phases, each testing slightly different treatment content. This paper reports the recruitment outcomes for the first phase.
The Project Quit Internet program was primarily designed and maintained by the Center for Health Communications Research at UM. Study participants were recruited from the memberships of GHC and the Health Alliance Plan (HAP) of HFHS. Both GHC and HFHS are not-for-profit integrated health care delivery systems. At the time of this study, GHC served more than 540000 enrollees (adults and children) in Washington State and Idaho. An estimated 200000 adults and children in the greater Detroit, Michigan area were insured through HAP and received services through HFHS. Both GHC and HFHS/HAP provide behavioral counseling and pharmacotherapy for smoking cessation as covered insurance benefits, but at the time of this study neither offered an online cessation program.
All participants in this study received access to a tailored, cognitive-behavioral treatment program for smoking cessation that was delivered via the Internet. Treatment varied by the type and intensity of tailoring, but all participants received a personally tailored program and a 10-week supply of NRT patches. All treatment was provided free of charge. The study protocol was reviewed and approved by the Institutional Review Board (IRB) of each collaborating institution.Recruitment
Participants were recruited through a combination of individual-level and population-level strategies. Each of the two health care organizations identified likely current smokers via either automated smoking status data collected during recent medical appointments (Organization 1) or documentation of smoking in electronic medical charts, use of an internal list of smokers collected during prior research, or lists of patients with smoking-related conditions who had previously been prescribed cessation medications (Organization 2). Thus, all invitees were known to have been recent smokers with a high probability of current smoking. Likely smokers were prescreened for minimal inclusion criteria (eg, age) and were mailed a study invitation letter. The letter content was comparable across both health care organizations, but not identical due to different IRB requirements. Both letters briefly described the Project Quit program and study eligibility criteria and invited smokers to visit the Project Quit website to learn more about the study and be screened for eligibility. Individuals could also inform study staff if they did not want to be contacted further about this research. Finally, each site allowed people to refer friends and family members to the program, as long as referred smokers were members of one of the health care organizations. Information on how to refer a friend or family member was included in the invitation letter.
After approximately three months, we determined that we needed to boost our monthly enrollment rate to reach our recruitment goal during the study time frame. In an effort to expedite progress toward our overall recruitment goal, we amended the protocol to include a reminder mailing to likely smokers. Reminders were sent to all individuals who, at that point, had not yet visited the website or opted out of further contact regarding the study. From that point forward, reminder letters were sent to all persons who, four weeks after they received the initial invitation letter, had not visited the website or opted out of contact.
We also utilized several population-level enrollment strategies. The study was advertised in each health care organization's quarterly membership newsletter and was the focus of a feature article in one newsletter issue at Organization 2. Ads appeared in three to four issues total, depending on the site. Each site also advertised through a variety of supplemental strategies. Organization 1 highlighted the program in one issue of its staff newsletter and on the "Join a Study" page of the institution's website. Organization 2 advertised the study during a local promotion of the 2004 Great American Smokeout and allowed physician and nurse referrals, though the latter was not widely promoted among staff. Participants were actively recruited from September 2004 to July 2005.
Letters were proactively mailed to 34533 likely smokers at Organization 1 (n = 18668) and Organization 2 (n = 15865). Quarterly newsletters were mailed to the entire membership of each health care organization, including approximately 563200 adults with GHC or HAP insurance coverage. Based on smoking prevalence data from automated medical records at Organization 1 and regional smoking prevalence estimates for Organization 2 , approximately 63180 adults at Organization 1 and 34506 adults at Organization 2 were smokers. At Organization 1, the staff newsletter ad was distributed to approximately 10000 employees, of whom 1000 were estimated to have been smokers based on internal smoking prevalence data among staff. It is not possible to estimate how many smokers were exposed to the other referral sources (eg, friend and family referrals, website posting).
Each recruitment strategy was associated with a unique referral code. Potential participants used these codes to log in to the Project Quit website. It is possible that some participants were exposed to more than one recruitment strategy (eg, invitation letter and newsletter ad); however, by using the referral codes we were able to track which promotional strategy they were responding to when they enrolled and to which health care organization they belonged. After logging into the site, individuals were able to read an overview of the study, be screened for eligibility, and provide informed consent.Participants
Individuals were eligible to participate if (1) they had smoked at least 100 cigarettes in their lifetime, currently smoked at least 10 cigarettes per day, and had smoked in the past 7 days; (2) were seriously considering quitting in the next 30 days; (3) were 21 to 70 years old; (4) were a member of GHC or HFHS/HAP; (5) had home or work access to the Internet and an email account that they used at least twice weekly; (6) were not currently enrolled in another formal smoking cessation program or currently using pharmacotherapy for smoking cessation; and (7) had no medical contraindications for NRT.
ResultsProject Quit Recruitment Response
During the 11-month recruitment period for phase one of Project Quit, 3256 people from both health care organizations visited the website; 2651 were screened for eligibility (81% of website visitors); 2011 were eligible (62% of website visitors); and 1866 enrolled (57% of website visitors).
Like all disruptive technologies, picture archiving and communication systems (PACS) solve some problems with new ways of working, but also bring fresh challenges in their wake. Information overload is one of those issues occupying some experienced PACS users.
As the technology enables radiology departments to see more patients per day, produce more studies per patient and more images per study, so the potential grows for huge amounts of information to be generated in an organisation’s PACS.
Questions then arise about how this is managed. Which studies should be processed? Where should they be processed and by whom? Which images should be sent for primary interpretation and which stored in archives - and for how long?
Not a new problem
Visitors to the major radiological congress, UKRC, this year were treated to an authoritative account of the issues from one the US’s experts on the subject, Dr Katherine Andriole of the Brigham and Women’s Hospital, Boston. She is also chair of the sub-committee managing the TRIP (Transforming the Radiological Interpretation Process) Initiative which is dedicated to three basic objectives:
- Improving the efficiency of interpretation of large data sets;
- Improving the timeliness and effectiveness of communication;
- Decreasing medical errors.
Dr Andriole had some reassuring news: the problem is not entirely novel. Since medical imaging was invented in the late nineteenth century, managing the information produced has always presented difficulties.
A position paper (subscription needed) by Dr Andriole and other TRIP sub-committee gives a full account of the history. The authors record that the early adopters of Wilhelm Rontgen’s “amazing new ray” had serious problems storing the large numbers of thick glass plates generated by the new diagnostic process. Not only were the plates heavy but volatile chemicals were used in processing.
Overload followed almost immediately as doctors sent large numbers of requests to early radiology departments, hoping to resolve longstanding questions and open up new lines of enquiry in all disciplines. The solution for hospitals in the twentieth century was to bring in more people to manage the growing workload – not an answer likely to win much approval today.
Dr Andriole told the UKRC that investigations on the current overload issues had even stretched as far a Hollywood where the film industry is learning to deal with huge amounts of computer generated graphics produced during modern filming and animation. The solution there seems to be to spend more money – again, not a popular option in cost-conscious Western healthcare systems.
Addressing the problem
TRIP has set itself the task of spearheading research, education and the discovery of innovative solutions to address the problem of information and image data overload.
Attempting to put a figure on the issue, the TRIP position paper refers to an informal study at the department of radiology at the Mayo Clinic, Jacksonville, Florida, which shows that roughly 1,500 images were generated and stored per day in 1994. At the same practice in 2002 and average of 16,000 images were acquired each day. It was estimated that, if the rate of growth continued at the same level, 80,000 images a day would be generated today. Borrowing a term from the aeronautics industry, the TRIP sub-committee concluded that radiologists were getting “beyond the limits” meaning the computerised element of their work was getting too complex for simple human control.
“Radiologists today sit at the controls of their increasingly ‘difficult to fly’ workstation facing a challenge in imaging and information overload that transcends the traditional quick fixes of more personnel or more time,” they wrote.
Dr Andriole explained the approach TRIP was taking, working with corporate partners in the imaging and IT industries. The quest sounds simple: “to optimise what the radiologist does well and let the computer do what it does well.”
But the reality is much more subtle. For example, as Dr Andriole explained, it is very difficult for expert radiologists to tell you what they are doing when they look at an image.
Nevertheless TRIP has defined six areas where it believes research must be done if progress is to be made in managing the ever-increasing volume of data and make best use of both human and technical resources. These are:
- Human perception
Research to develop standards for image quality and display.
- Image processing and computer-aided detection (CAD)
Studies to develop aids to the perception of features on an image and to develop a supportive workstation for the future. This would incorporate computer aids such as cueing, overlays and annotation. Decision support tools, simple reminder techniques, data mining and access to reference libraries are also included in this research area.
This area of research looks at new ways of displaying medical images on screen.
- Navigation and usability
Research which looks at the increasing use of 3D and motion in imaging, virtual reality fly-throughs and hand-eye cueing instruments. In addition, hand-held devices will make images more readily available at the point of care.
- Databases and integration
The TRIP sub-committee says advances will be essential in the integration of hospital and radiology information systems with PACS and speech recognition systems. It advocates greater adoption of the framework developed by Integrating the Healthcare Enterprise (IHE) http://www.ihe.net/ .
- Evaluation and validation
A research area covering the development of objective methodologies for radiological imaging and as well as standard datasets for testing, comparison and collaborative research.
TRIP is a US initiative but some of the issues the initiative raises will resonate with UK users. In particular issues such as integration with a wide variety of other hospital systems will surface, especially as NHS England’s drive for ‘ruthless standardisation’ appears to be undergoing modification and moderation.
Research interests coincide too. For example, at the recent Clinical Care Computing conference in London, Dr Paul Taylor of the Centre for Health Informatics and Multiprofessional Education (CHIME) at University College London spoke about his research on clinical decision support tools in mammography screening.
Currently he has found the tools tend to have high sensitivity but low specificity and work is needed to tune any prompting system to reduce inappropriate false positives so that they are not routinely ignored. A slide presentation from the Clinical Care Computing conference programme and presentations section is available at www.abies.co.uk.
With the NHS’s drive to install PACS widely across the country in full swing and the decision to order and install the equipment taken, the coming years seem likely to bring another interesting wave of work focused on making the best use of PACS, the computer aids that can be used with the new systems - and the people who work with those tools.
(extraído do "The British Journal of Healthcare Computing & Information Management" - February 2006} Autor: Chris Blenkhorn is a Consulting Systems Engineer with Cisco Systems Ltd and a member of Cisco’s UK public sector team, where he specialists in healthcare networking.
Traditionally, NHS patients have travelled to hospitals for tests and consultations with clinical specialists. With the UK population set both to grow and age, however and with the consequent greater demands for new healthcare procedures and treatments - this may no longer be possible. Long-established patterns of healthcare such as these may have to transform if the NHS is to the Government and patient expectations within its budget.
The reality, of course, is that healthcare has been changing for some time in order to reduce costs and increase efficiency. The need to liberate funds for reinvestment and to change spending priorities has been substantial. Specialist clinical resources are being relocated into regional or national centers, and an increasing number of hospitals no longer have specialists in every discipline. Patients are being monitored at health centers or in the community rather than in hospital, especially when suffering from chronic conditions.
The natural consequence of this has been some reduction in contact between the patient and the clinician. However, many believe that the innovative use of IT and network technologies can help redress this situation, and there have been many attempts to introduce telemedical and telecare services in recent years. Unfortunately many of these services have not been successful, often because of the lack of suitable network technologies. It is instructive to look at recent major advances in this area and see the huge potential for networking to drive advances in telecare.
Telecare services depend critically on the availability of standards, and on ready access to the right local (LAN) and wide-area network (WAN) services. In the past these have not always been available, hampering service development, but advances have recently occurred in three areas - interconnection and inter-working standards, high speed, vide-capable links between NHS sites, and high-performance network links into the home.
Interconnection and interworking standards.
Standards are critical for the development and effective delivery of all aspects of IT. Telecare requires standards for physical connection to medical devices and system end points, and for logical communication between end points. Physical connection to systems and end points is now, in practice, by Ethernet local area network (LAN), or by lEEE 802.11 wireless connection (WiFi). Both of these can be provided easily and cost-effectively in the hospital, clinic or at home, and many hospitals have already implemented overlay wireless LANs (WLANs) for telecare and other mobility projects. Logical communication between end points uses Internet Protocol (IP) - the communications protocol that drives the Internet and most networked IT applications. The information modes used in telecare - data, voice and video - are all now fully standardized to operate IP.
Hígh-speed, video-capable links between NHS sites
Many attempts to introduce telecare services in the past were based on the use of NHSnet - the old NHS national network - for communication between NHS sites. This was not always successful, as NHSnet did not provide sufficient bandwidth or adequate quality of service - both being prerequisites for voice and video traffic. Projects either had to change the scope of their services, or were forced to install special-purpose network links, the cost of which often eroded business benefits.
The Government has recognized the importance of enabling network infrastructure for all aspects of healthcare delivery. The NHS National Programme the for IT (NPfIT) will deliver N3, the new national network, to provide robust, secure and standardised network connectivity to all NHS clinical locations. N3 has the ability to support multimedia traffic for telecare, and positions trusts very favorably for the development of site-to-site telecare services.
Network links into the home
In the past it was only possible to link into patients’ homes via standard telephone connections. These connections were slow and inflexible, and furthermore affected patients’ use of their telephones. The Government’s Broadband Britain initiative, however, has accelerated the availability high-speed digital subscriber-line (IDSL) connections across the country. While DSL also uses existing telephone connections, it does not affect normal telephone use and can be provided in a matter of days without any changes to home wiring. DSL has the additional benefit of ever-decreasing cost points.
Within the home, medical monitoring devices can connect to a DSL service via very simple ‘plug and play’ methods - a simple Ethernet cable, or a WiFi connection for greater flexibility. In the future, DSL may not be required at all, at least in urban areas, as medical devices in patients’ homes will be able to connect directly to WiFi broadband services.
Business need and technology driving innovation
We have mentioned the business need for more efficiency in the use of clinical resources. The very substantial developments in network technologies and the availability of enabling network services through N3 make this now possible.
This combination represents a clear platform for innovation. If fully exploited in the future, it could lead to the next major step in the transformation of healthcare services after the current deployment of the National Programme’s IT applications suite. Indeed, it is possible that telecare services such as teleconsultation, telediagnosis and telemonitoring could be incorporated into the National Programme in the future.
Linking the patient and clinician
Teleconsultation services provide direct video links between patients and clinicians. This benefits patients by increasing access to specialists and reducing the need for travel. Teleconsultation over ISDN circuits is already in use in the NHS, for example for out-of-hours consultations between community and acute hospitals, although video quality can be Poor. These services are likely to become commonplace with N3, which has been designed to support high-quality video connections. Video telephony now available in a form fully integrated with voice telephony, so there is no need to provide special-purpose networks for patients to consult clinicians. Looking to the future, 3G wireless telecommunications devices will support a suitable quality of video, and it will be possible to extend consultation directly into patients’ homes.
Centralising diagnostic services
Telediagnosis services permit a patient’s scan or image to be sent to a remote specialist for diagnosis and report. The benefit to the NHS of this approach is the more effective use of skilled and centralised clinical resources. The benefit to the patient will be faster reporting following scans and tests.
Scan images may be sent over IP via file transfer or attached to emails, but image files can be very large and require significant bandwidth. Images of external, eg dermatological, conditions can be handled photographically or over video links. N3 provides high bandwidth and is video-capable, offering an excellent vehicle for the development of these telediagnosis services.
Remote monitoring in hospital, clinic and in the home
Telemonitoring often referred to as telemedicine in the past, permits medical devices attached to patients to be accessed and controlled from a central monitoring statiun. The network links connecting device and monitoring statiun may take a variety of forms - wired or wireless LAN links within hospitals, links over N3 between clinical locations, and GPRS mobile-phone-network or DSL links from patients’ homes and in the community.
Telemonitoring can be found in many guises within the NHS. ln its simplest form it can provide a link between a beside medical device and a nurses’ statiun. Nowadays medical devices are becoming WiFi capable, permitting active monitoring as a patient is moved from ward to ward, or from ward to theatre. In the future, telemonitoring will be increasingly available in the community and in patients’ homes. This will be particularly important fur successfully managing chronic conditions without taking up valuable hospital bed space.
The NHS is witnessing the fortunate co-incidence of business need — to deliver healthcare services more cost effectively and the tools to do so — new network technology standards and highly capable, but low-cost, network products.
This offers an excellent opportunity fur NHS trusts to exploit networking for telecare to benefit patients and clinicians, particularly as the National Programme is providing the enabling N3 infrastructure.
There are already many examples of telecare in operation, particularly teleconsultatiun and telediagnosis, and every trust should have the development of business plans high on its priority list.
Chris Blenkhorn is a Consulting Systems Engineer with Cisco Systems Ltd and a member of Cisco’s UK public sector team, where he specialists in healthcare networking.
(Extraído do "The British Journal of Healthcare Computing & Information Management"- February 2006)
(extraído do NewsFactor Network - February, 2006) Autora: Walaika K. Haskins
"We have been looking at this as an opportunity to improve the quality and efficacy [of medical services] if the healthcare industry would adopt the tech that every other industry has already adopted," said Eric Brown, an analyst at Forrester Research. "The world is out there with technology and only 15 percent of doctors use a computer to record medical information."
For several years, hospital administrators, privacy advocates, and policymakers have debated the benefits and drawbacks of electronic medical records (EMR).
According to a Healthcare Information and Management Systems Society (HIMSS) survey last week of some 205 healthcare executives representing more than 473 U.S. hospitals, the time for talking is over.
The survey found that hospital CIOs already have begun switching from paper records to electronic files or anticipate making the switch in the near future.
For the purpose of the survey -- released during the annual HIMSS conference held in San Diego last week -- an EMR was defined as the record in which a person's "lifetime health status [is maintained] in a completely paperless fashion."
The survey found that about 25 percent of hospital administrators have moved their healthcare organizations to a fully implemented electronic medical records system. That number represents an increase of some five percent from 2004 and 2005, when slightly less than 20 percent of respondents reported having a functioning EMR system.
The number of hospitals that have begun the process of installing an EMR system remained roughly the same as in previous years. Nearly four out of 10 hospitals reported that they had contracted for an EMR system or had begun installation. Another 25 percent said that they have plans to deploy an EMR system, but have yet to begin actual installation.
Only one out of 10 hospitals reported no plans to move to EMRs, a number that has decreased significantly since the 2004 survey, when one out of five respondents indicated their hospitals did not plan to adopt an EMR system.
According to Eric Brown, an analyst at Forrester Research, that number is most likely comprised of smaller hospitals. "Scale in this instance is very important," he said.
It's the Economy
Brown said the reason a growing number of hospital administrators have begun deploying an EMR system after decades of debate is that previously changing to EMRs was deemed a healthcare issue.
"We have been looking at this as an opportunity to improve the quality and efficacy [of medical services] if the healthcare industry would adopt the tech that every other industry has already adopted," he said. "The world is out there with technology and only 15 percent of doctors use a computer to record medical information."
The industry, Brown said, is clearly experiencing a tipping point in terms of adoption because the problem is no longer about healthcare alone. Rather, he said, it is about economics.
In the last five years, the healthcare industry has experienced a rapid growth in the cost of healthcare. In addition, the country has neared the point where the Baby Boomers are reaching retirement and are enrolling in Medicare.
"My running joke is that the electronic record has been five years away for 20 years," said Brown. "What has changed is that now someone says that this is no longer a health problem; it is an economic problem."
Hospitais do mundo descobriram que o Prontuário Eletrônico é a melhor opção para redução de gastos na área de saúde. Agora falta o Brasil adotá-lo
Os sistemas tecnológicos de saúde são uma realidade inquestionável e se tornaram focos de investimentos em hospitais, clínicas de saúde e laboratórios. Graças à agilidade proporcionada por essas tecnologias, o atendimento aos pacientes é considerado eficiente e satisfatório. No entanto, se olharmos de forma crítica o processo de atendimento e gestão nas instituições de saúde no Brasil, descobriremos que a realidade vivida no momento está longe do ideal.
Há poucos anos, um relatório do Institute of Medicine advertiu que os erros médicos evitáveis resultam entre 44 a 98 mil mortes dentro dos hospitais nos Estados Unidos, gerando perdas da ordem de dois bilhões de dólares todos os anos. Já a organização norte-americana, Maimonides Medical Center, mostrou que a introdução de tecnologia como o Prontuário Eletrônico do Paciente reduziu em 30,4% o tempo de permanência do paciente no hospital. Da mesma forma, o suporte à decisão auxiliou o laboratório do hospital na redução de 48,9% dos exames de urina e em 41,6% dos exames de microbiologia. Esses ganhos são frutos da introdução informatizada dos protocolos clínicos que podem ser monitorados com alertas automáticos e instantâneos, que apóiam a decisão médica e reduzem o tempo da ação clínica.
Seria a chamada “Medicina Invisível”, que embora não possa ser tocada ou vista a olho nu, está por trás dos procedimentos e organizações existentes em um hospital ou clínica de saúde. Adotado por diversas instituições de saúde públicas e privadas ao redor do mundo, esse sistema tem mudado o conceito de trabalho, assim como, despertado o que antes era considerado inimaginável. E, em alguns anos, a idéia é que as pessoas sejam cidadãos do mundo e, independente de onde estiverem, tenham atendimento rápido e eficiente em hospitais ou outras instituições. É a rede de saúde comunitária, que armazena de forma organizada todas as informações sobre a saúde das pessoas, exames e cirurgias, já realizados.
A adoção do Prontuário Eletrônico é pauta de importantes discussões, pois tem mostrado eficácia na gestão, produtividade e qualidade no atendimento aos pacientes. É claro que ainda existem pessoas e entidades resistentes à adoção desse sistema, mas o tempo e a prática tornarão a discussão uma grande obviedade. Muitas vezes o debate direciona para o impacto nos custos das organizações que o implementariam, mas os ganhos são significativos após sua introdução e uso. Segundo o Departamento de Saúde dos EUA (HHS), essa rede de informações pode auxiliar as instituições a economizar cerca de 140 bilhões de dólares por ano.
No Brasil, a Medicina Invisível já é realidade em alguns locais. O Hospital Português da Bahia, por exemplo, investiu num projeto que integra todos os seus processos e departamentos, gerenciando toda produção de serviços clínicos com a introdução do Prontuário Eletrônico via web. E ao questionar quais os fatores motivadores para tal implementação, a resposta é certeira: melhoria da eficiência operacional e garantia da oferta de maior segurança e efetividade aos médicos e gestores do hospital. O escopo do projeto está centrado na automatização dos processos internos, da entrada do paciente até a sua saída. A partir de uma pulseira com código de barras no pulso do paciente, médicos e enfermeiras têm acesso às informações de forma rápida e eficaz. Outro ganho é com funcionários de apoio técnico, que controlam melhor o fluxo de materiais e medicamentos no hospital.
Hoje, grande parte das instituições de saúde no mundo já encara o processo de implantação de soluções de Prontuário Eletrônico como forma de redução de custos. Além disso, o sistema também deverá ser usado para identificar com maior velocidade possível os pacientes em risco, de modo a estimular ações de prevenção antes do agravamento do diagnóstico.
Para os gestores de instituições de saúde públicas ou privadas deixo meu recado: é absolutamente necessário perceber a importância de adotar o Prontuário Eletrônico do paciente. Esse sistema, considerado uma das maiores revoluções na área da gestão hospitalar, é um instrumento fundamental para o controle de gastos excessivos na área, assim como rastreamento de epidemias.
Carlos Eduardo Kühl Nogueira Diretor Geral da InterSystems para Países Emergentes (América Latina, África, Índia e Oriente Médio).
For the past month, 82-year-old Salvatore Fischer has been getting a daily check-up in his North End apartment. But instead of a visiting nurse, his healthcare provider is a compact touch-screen monitor that would look right at home in the Jetsons' kitchen.
Around 7 a.m., Fischer kicks a digital scale into action, sending his weight wirelessly into the monitor propped on his counter. He clips his finger into a device that measures the amount of oxygen in his blood, and straps on a Velcro blood-pressure cuff. He mashes a thick fingertip into the word ``send" on the monitor's liquid-crystal touch screen, and the information travels through his phone line to a computer readout in Rockland.
``The way I understand it, this machine takes the place of a nurse," said Fischer, who lives on his own despite congestive heart failure, obstructed lungs, and diabetes. ``If I gain five pounds, say from one day to the next, I'm in trouble. I can't cheat because they know what's normal -- they'd have a nurse here within a half-hour."
For more than a decade, medical-device makers have trumpeted so-called ``telehealth" hookups as a revolution in the costly American medical system. The idea is that by tracking vital signs remotely, doctors and nurses can keep patients comfortably at home while reserving their attention for the most serious cases. They can also save the expense and disruption of hospital visits by catching signs of trouble before a patient needs an ambulance.
Now an increasing number of companies have begun to compete for the home-monitor market. But hobbled by confusing technology and a Byzantine health insurance system that pays for nurses to check on patients in person but not from a distance, the idea has been slow to take off. Of the tens of millions of Americans with chronic conditions such as Fischer's, only a small fraction have a home monitor.
``Just because you have a nifty way of doing something doesn't mean that you can create a market," said Dr. Joseph Kvedar , director of telemedicine for the Partners HealthCare System in Boston.
The home-health division of Partners, which sends nurses to visit patients who need regular checkups, is among the small but growing group of agencies nationwide that have spent money to install remote-monitoring systems. After pilot programs suggested that patients with weakened hearts could benefit from home monitors, Partners Home Care recently began buying and installing $2,500 telehealth systems for 50 patients, including Fischer. The agency says 250 to 300 of its patients could ultimately benefit from home monitors, and hopes to have that number in place by the end of next year.
``We used to find that patients with congestive heart failure, even if we were visiting three times a week, we would miss a change in their weight, which is one of the first indicators their heart is failing," said Judy Flynn , the agency's chief clinical officer. ``By the time we'd get there to check it out, they'd need to be admitted to the hospital.
In perhaps the largest national rollout of such systems, the US Department of Veterans Affairs has spent $20 million to install some 15,000 monitors across the country, and expects to have 50,000 in place by 2009.
The VA has found the systems cut patient care costs by about one-third. Each trained nurse watches daily vital signs of about 150 patients, some of whom also have video monitors for personal consultations. Abnormal results are red-flagged so a patient can receive a phone call or a personal visit.
``This may seem a little bit fanciful, but it's a little bit like an air-traffic control system for patients," said Dr. Adam Darkins , who runs the VA's program.
Darkins also said patients don't seem to mind the drop-off in face-to-face visits.
``The satisfaction levels are over 90 percent," he said. ``It's very intuitive, and they feel they're in regular contact."
Encouraged by such feedback, Honeywell International Inc. in 2004 bought HomMed , a leading producer of household monitors. Earlier this year, giant Philips Electronics NV launched its own system, Motiva . Another company, Viterion TeleHealthcare LLC , is a joint venture of Panasonic and Bayer. They compete with a broad constellation of private firms.
Still, industry observers say fewer than 200,000 people -- and maybe less than half that number -- have monitors. Philips's Motiva, which launched in May and is based in Massachusetts, has not yet sold any units. Even veteran players in the industry, such as California-based Health Hero Network Inc. , have fewer than 30,000 units in people's homes.
One reason is the unresolved question of who should pay. Remote monitors, combined with nurse coverage, are too expensive for most patients to buy out-of-pocket, so they are usually sold to home health agencies or disease-management companies paid to handle chronically ill patients. Since the equipment isn't considered a therapeutic expenditure, and because no large-scale studies have proved cost-effectiveness, Medicare and most private insurers won't pay for the equipment, leaving cash-strapped healthcare agencies to foot the bill.
``We see the patients; we know the monitoring would work. But if we go out and buy it and we do a great job, the benefits really go to the insurance company," said Marcia Reissig , a nurse and chief executive of Partners Home Care.
Partners and others say buying monitors sometimes does makes sense for an agency, but only in a small subset of patients. Medicare pays a flat fee to care for patients; Reissig said a typical nurse visit costs about $78, and a monitor costs up to $200 monthly to buy and operate. If a monitor can cut two or three monthly nurse visits, it helps keep the cost of care below what Medicare pays.
That type of analysis limits the spread of the devices, however, because it doesn't account for savings from reduced hospitalizations, which don't benefit the agency that buys the equipment.
``There are a number of people who we think could benefit" from monitoring, ``but there isn't that return," said Reissig, who scrambles for grants and donations to get more monitors to patients.
Another obstacle to widespread monitoring is the complexity of the devices. Many are basic vital-sign monitors like those in Fischer's apartment, which can be customized.
For someone with diabetes, a glucose meter can keep tabs on blood sugar levels; for someone with asthma, a device called a spirometer checks lung strength. Some machines even track whether a patient opens pill bottles at the proper times daily.
But the diversity of offerings has created its own problems. Patients who need home care are unlikely to be able to navigate a variety of systems and interfaces, and most companies sell proprietary devices that don't communicate with competitors' equipment. That makes caregivers hesitant to commit money to a single system, said Reissig.
When Partners decided to buy systems for patients like Fischer, she said, they winnowed it down to six vendors and tried out three. One system, based on cellphones, had screens too small for elderly patients to read. Another was so heavy that staffers couldn't lift it into their cars. Some gave flagrantly inaccurate readings after being installed.
Fischer said his monitor, made by Virginia-based ViTel Net , has been reliable, and he operates it with ease, not hesitating when the screen dotted with cheerful-looking icons flashes an obscure message like ``Sending basket to host authsmtp.juno.com."
But then, as a World War II veteran who installed electronics at the Charlestown Naval Shipyard, Fischer may not be a typical customer.
``I installed the original computers," he said, looking across a neat lineup of prescription pill bottles at the device on his counter. ``You wouldn't believe how big they were."
The Last Frontier' on Internet Draws Big Names and Their Money
By Annys Shin
(Extraído do Washington Post - August 8, 2006)
Ninety-five million Americans -- about 80 percent of online adults -- have searched the Web for health information in the past year, and the overwhelming majority have been disappointed.
More than 70 percent of those searchers either did not find what they were looking for or had a hard time knowing what to believe, according to market research studies by Jupiter Research and Yankelovich Inc.
That frustration has attracted some famous deep pockets, including America Online co-founder Steve Case, his former employer Time Warner Inc., the Carlyle Group and Allen & Co. Together, they have put more than $100 million into building virtual destinations that offer consumers something beyond disease encyclopedias.
Some want to make it as easy to choose a doctor as a restaurant. Others eventually hope to offer "virtual assisted living" by monitoring medicines or pacemakers remotely, so the elderly can stay in their homes longer.
"The health category is the last frontier where the Internet has not yet transformed that industry, the way it has done for travel, finance, and commerce," Wayne T. Gattinella, chief executive of WebMD Health Corp., said.
Harnessing the Web to make health care more user-friendly has been a holy grail for entrepreneurs since the earliest days of the dot-com boom. But like many online content businesses, they failed because they could not figure out how to make money.
"The mistake that's been made by a lot of entrepreneurs who have pushed those approaches was an 'if we build it they will come' philosophy," said Jay Savan, a benefits consultant in the St. Louis office of Towers Perrin.
Some sites, such as Drkoop.com relied too heavily on advertising revenue. Named for the former U.S. surgeon general C. Everett Koop, it was worth more than $1 billion at one point, but went out of business in 2001 not long after going public. Its assets -- mainly Internet domain names -- were later sold for $186,000 in bankruptcy court. It is now owned by the HealthCentral Network, an Arlington-based company that is part of the second wave of health information Web businesses.
The dominant player in the field, 10-year-old WebMD, survived by merging with Healtheon, founded in 1996 by Netscape co-founder Jim Clark. He saw the Internet as the best way to bring doctors and patients together and "get all the other [jerks] out of the way." The combined company, which also delved into insurance claims processing, physician practice management software and plastics, did not post a profit until 2003.
The nearly $2 trillion health-care industry remains as fragmented and frustrating as ever. But the market for online health information and services has changed enough to make it a viable business, investors, entrepreneurs and analysts said.
A May 2005 Pew Internet & American Life Project study -- which reported that about 95 million people have searched the Web for health information -- found more people were turning to the Web for information about diet, exercise and over-the-counter drugs. They also do more "health homework" online, such as comparing physicians and hospitals.
"The consumer is starting to expect the same information with respect to a health provider as they expect with an airline or investment vehicle," Gattinella said. "Those are the big forces that will accelerate changes in our industry in the next five years."
It will still be a while yet before finding a heart surgeon is as easy as booking an airline ticket on Orbitz or Travelocity.
"I don't see we're at an inflection point because there is still major limitation on quality information available . . . [and] still limitations on cost information. Those limitations on data are not about to disappear," said Paul Ginsberg, president of Health System Change, a non-partisan research organization in Washington.
But with out-of-pocket medical expenses rising faster than family income, and a small but rapidly growing number of the insured turning to health-savings accounts and high-deductible health plans, consumers have begun shopping around, if not for the best hospital for coronary bypass graft surgery, then at the very least for prescription drugs.
Just as important as changing consumer habits, advertisers are also spending more money on Web ads.
WebMD spun off last year in a successful initial public offering and has seen its ad revenue grow. Last week, it reported a narrower second-quarter loss of $1.16 million, down from $1.5 million a year earlier. Advertising contributed to a 38 percent revenue increase.
As a result, big-name investors are once again bankrolling health information Web sites.
Time Warner has sunk money into Waterfront Media, a four-year-old Brooklyn publisher of self-help information founded by Ben Wolin and Michael Keriakos, two former executives with spirituality and faith Web site Beliefnet.
Unlike three years ago, when money for Internet start-ups was harder to come by, the company this past year raised $6 million from several sources, including Time Warner, to build EverydayHealth.com. The site, set to launch later this year, will deliver personalized health information, even by phone or personal digital assistant, to more than 11 million people who have created profiles on one of Waterfront's existing health-related sites.
The Carlyle Group, Allen & Co., and Sequoia Capital last year invested in HealthCentral Network, formerly ChoiceMedia Inc., which bought a collection of sites created during the dot-com boom and revamped them into a network of 25 condition-specific destinations that offer physician-reviewed information and the ability to connect with ordinary people who have experienced the same illness.
Both HealthCentral Network and Waterfront rely on advertising, and could benefit from a shift among pharmaceutical companies away from television and toward the Web, where they have unlimited time and space to relay such information as side effects.
Revolution Health, probably the most ambitious of WebMD's would-be competitors, is backed by Case and board members/investors such as Carly Fiorina, former chief executive of Hewlett-Packard Co., Franklin D. Raines, former chairman and chief executive of Fannie Mae, and Stephen Wiggins, founder of Oxford Health Plans.
Its Web portal, Revolutionhealth.com, is slated to launch in the fall. Revolution Health plans to offer, in addition to the usual searchable encyclopedia of disease information, tools for finding doctors, making appointments and managing health-related expenses.
What sets Revolution Health apart is its offline investments in walk-in retail clinics at places such as Walgreens and Wal-Mart for minor medical issues, and in insurance providers that offer high-deductible plans directly to consumers.
"It's best to attack this problem through multiple prisms and build a set of services that can attract an audience and can aggregate benefits to those consumers as well as those who want to provide services to those audiences," Case said.
RevolutionHealth.com plans to make money by selling customized services to employers and health plans, selling advertising and charging membership fees for a suite of premium services, which may include access to better-quality doctors.
"We don't want to be the place you go to when you're not feeling well. We want it to feel more like your buddy list and your portfolio, a service that engages you because it's personalized, several times a day, not several times a year," Case said.
There were rumors earlier this year that Google was also looking into the delving into the online health information business, a development that does not surprise any of the current players.
"I think you'll see several other companies coming into this space because it is such a huge marketplace and so underpenetrated at this point," Martin J. Wygod, chairman of WebMD, told analysts during a May conference call.