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Study Finds Doctors with EHRs Have More Complete Patient Information

An interesting article pointing out the true information-intensive nature of healthcare. I agree that EMR's "alleviate but do not solve the problem" but point out that this observation is what medical educator and activist Dr. Victor Satinsky would have called an observation by a "master of the obvious." There may never in our lifetimes be a complete unified registry (either virtual or physical) of all healthcare information on everyone. However, the EMR is a key component whose implementation must not be delayed and costs increased by hospital politics (a.k.a. mismanagement), IT/clinician/executive territorial and ego battles, incompetence, unscrupulous software vendor business practices (e.g., the <a href="http://www.healthdatamanagement.com/html/PortalStory.cfm?type=vend&DID=10279">HBOC medical software company scandal</a> of several years ago), and other biomedical IT <a href="http://home.aol.com/medinformaticsmd/failurecases.htm">sociotechnical issues and dysfunction</a>.-- SSStudy Finds Doctors with EHRs Have More Complete Patient InformationFebruary 3, 2005 By M.L. Baker Patients' care may be adversely affected by missing information in as many as 220 million patient visits each year, according to a study published by the Journal of the American Medical Association this week. Electronic medical records alleviate but do not solve the problem. Though missing information is blamed in about 16 percent of medical errors, this is the first survey to document how frequently primary care clinicians lack information during office visits. Information was missing in one of seven visits. Clinicians estimated that the missing information was likely to adversely affect the patient's medical care and could cause delayed care or redundant services 60 percent of the time. In 45 percent of the visits, the clinician reported spending five or more minutes unsuccessfully searching for the information, time that could have been spent with the patient. Only about 7 percent of physicians, physicians' assistants, and nurse practitioners reported having full EHRs (electronic health records), but this group was 60 percent more likely to have complete information. Doctors' offices in rural areas, which tend to rely on a smaller number of vendors for laboratory results, were 48 percent more likely to have complete information.Don Mon, vice president of practice management at the American Health Information Management Association, said that clinicians with EHRs probably had more complete information because the system actively prompts physicians to collect information. Clinicians reported that most (52.3 percent) missing information was outside the medical practice but inside the United States. However, information was just as likely to be missing if a practice had electronic access to a primary hospital. Nevertheless, Mon said that the study pointed to the need for a national health information network so that different systems could communicate. "Hospitals might have an electronic record and a physician might have an electronic record, but we don't have the means to exchange them. They are acting like islands." In an editorial accompanying the study in the JAMA, Nancy Elder and John Hickner wrote, "There are thousands of electronic databases, even within the same community, that cannot communicate with each other." In addition, clinicians who reported having hybrid or partial EHRs were just as likely to have missing information as those without such systems.New patients were more than twice as likely to have missing information as patients who were returning to the same doctors' offices. Information was three times more likely to be missing for patients with five or more medical problems, and 80 percent more likely to be missing for recent immigrants. The survey did not ask clinicians whether any information was missing, but asked specifically whether information important for patient care and known to exist was missing during the visit. Information that was not in a patient's file when a doctor visit began was not counted as missing if it was located before the visit ended. In 36 percent of visits with missing information, clinicians or staff had spent more than five minutes looking for information while the patient was in the office. The survey, led by Peter Smith at the University of Colorado Health Sciences Center, was conducted for 1614 visits with 253 physicians, physicians' assistants or nurse practitioners at 32 clinics. Laboratory results were reported missing most often, in about 6 percent of visits, followed by letters and dictations, history and physical examinations, radiology results and medications.

Study Finds Doctors with EHRs Have More Complete Patient Information

An interesting article pointing out the true information-intensive nature of healthcare. I agree that EMR's "alleviate but do not s...

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Forbidden Knowledge, with Irony

Science just published a qualitative research article about scientists' "self-censorship." The term we have used before for this behavior is "suppression of research." A news summary is <a href="http://msnbc.msn.com/id/6947844/">here</a>, and the article is <a href="http://www.sciencemag.org/cgi/content/full/307/5711/854">here</a> but requires a subscription. (The citation is Kempner J, Perlis CS, Merz JF. Forbidden knowledge. Science 2005; 307: 854.) Many of those interviewed for the study were from the life sciences, although none were apparently physicians. The article's introduction mentioned "social control of scientists," particularly regarding studies of "human cloning and embryonic stem cell creation," and certain "government sponsored research." It cited examples of the latter included studies of gay men and prostitutes and of sexual behavior more broadly, and about potential bio-terror agents. The sorts of topics the scientists considered "sensitive" included "human cloning, embryonic stem cells, weapons, race, intelligence, sexual behaviors, and addictions, as well as concerns about using humans and animals in research." It's an interesting article that adds to our knowledge about suppresion of research. However, I was startled to find almost no discussion of suppression of research about commercial products due to pressure from those with financial interests in the products. Clearly, this is a prevalent problem in health care, complicated, in some famous cases, by the quickness with which universities and teaching hospitals have succumbed to such pressure. It is also ironic that most of the examples seemed to be of pressure from groups that may have had a right-wing tinge, e.g., pressure against stem-cell research, or studies of sexual behavior. Of course, as quick perusal of <a href="http://www.thefire.org/">the FIRE web-site </a>shows, at universities much of the pressure on free speech and academic freedom comes from the other end of the political spectrum. Perhaps the authors' emphasis mainly reflected their small, and probably not very generalizable study sample. But it seems even more ironic that a report from university researchers on suppression of research seems to leave out some of the most salient sources of pressure on academics to suppress. But maybe this just adds to their own argument.

Forbidden Knowledge, with Irony

Science just published a qualitative research article about scientists' "self-censorship." The term we have used before for t...

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Caught in the Cross-Fire: Merck Tried to "Neutralize" Vioxx Opponents

Here is a new kind of example of how physicians have been caught in cross-fires between competing interests. The <a href="http://www.nytimes.com/2005/02/11/business/11merck.html">NY Times reported </a>today about some newly obtained documents about how Merck marketed Vioxx. Particularly striking were references in them to the need to "neutralize" physicians who Merck marketers perceived were Vioxx opponents. To quote the Times, "In the 'neutralize' documents written by a Merck marketing executive, company officials identified dozens of influential but 'problem' physicians whom [sic] the company believed had either a negative view of Merck or Vioxx or were active boosters of Celebrex. To win them over, the documents show, Merck officials planned to offer them carrots like clinical trials, posts as consultants, or give them grants." A form that Merck used internally to request payments for doctors asked for "Expected Outcome/ Return on Investment." When I first read the headline, I feared "neutralization" meant something even more sinister. But the reality was bad enough. This is a vivid case of how when physicians are caught between powerful organizations, here, competing drug companies, the patients' interests seem to come last.

Caught in the Cross-Fire: Merck Tried to "Neutralize" Vioxx Opponents

Here is a new kind of example of how physicians have been caught in cross-fires between competing interests. The NY Times reported today abo...

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Lo Bat for Implantable Cardiac Defibrillators

<a href="http://today.reuters.co.uk/News/newsArticle.aspx?type=healthNews&storyID=2005-02-11T195110Z_01_N11525845_RTRIDST_0_HEALTH-HEALTH-MEDTRONIC-DC.XML">Medtronic warned physicians </a>today about the possibility of battery failures in one of its models of implantable cardiac defibrillators (ICDs), 87,000 of which were manufactured before 2003. The market for these devices has recently expanded, since Medicare approved their prophylactic use for patients with congestive heart failure. Medicare <a href="http://www.indystar.com/articles/5/218124-6655-010.html">planned to pay </a>from $28 to $36K for the device, and the procedure to implant it. I believe (but cannot find evidence at the moment to prove) that the price of the actual ICD is around $25K. If so, given that its circuitry cannot be that complex in this day and age, one would think that this would have been enough to buy an extremely reliable battery. This reinforces <a href="http://hcrenewal.blogspot.com/2005/02/interesting-report-from-boston.html">the questions I recently raised </a>about the pricing of medical devices versus their value to the patient.

Lo Bat for Implantable Cardiac Defibrillators

Medtronic warned physicians today about the possibility of battery failures in one of its models of implantable cardiac defibrillators (ICDs...

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"FTC Seeking to Break Apart Hospital Merger"

"FTC Seeking to Break Apart Hospital Merger"

Its about time that the government started paying attention to the concentration of power within hospital groups, and, of course in ever lar...

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An Interesting Report from Boston University on Controlling Health Care Costs

An interesting <a href="http://dcc2.bumc.bu.edu/hs/Health%20Costs%20Absorb%20One-Quarter%20of%20Economic%20Growth%20%202000-05%20%20Sager-Socolar%207%20February%202005.pdf">report</a> on entitled "Health Costs Absorb One-Quarter of Economic Growth, 2000 – 2005" from the Boston University School of Public Health has received a little <a href="http://www.latimes.com/news/nationworld/nation/la-na-health9feb09,0,2550528.story?coll=la-home-nation">notice</a> in the press. It's long, so I haven't been able to review it in detail, but it makes some pretty good points (although also seems to leave out some important issues that get discussed on Health Care Renewal.) <ul><li>It suggests that waste, bureaucracy, and fraud account for large proportions of health care costs. The data that justifies this assertion, however, is not immediately obvious.</li><li>It notes that prices are much too high, but seems to imply that this is a generalized pheonomenon. The example it uses, for example, is a general comparison of drug costs in the US and Canada. The report does not seem to grapple with discrepancies of price and value, for example that some drugs seem inordinately expensive compared with their benefit/harm ratio, while others may be quite cheap. Such discrepancies between price and value, of course, seem to occur for all kinds of health care products and services.</li><li>Its discussion of waste, fraud, and bureaucracy skirts the issue of ill-informed, incompetent, self-interested, and even corrupt leadership of health care organizations. For example, its discussion of fraud seems to focus mostly on that perpetrated by individual providers on insurance companies. How the Allegheny bankruptcy (<a href="http://www.acponline.org/chapters/ri/nl-fall04.pdf">here</a>, on p. 5) , or the <a href="http://hcrenewal.blogspot.com/2005/02/end-of-anechoic-effect-editorial.html">conflicts of interest at the NIH </a>would have fit into this framework aren't clear.</li><li>It recognizes that physicians actually make most of the important health care decisions for individual patients, and hopes that better informed, more evidence-based decision making will help. In fact, it puts most of the onus of controlling costs on physicians, while acknowledging that this is quite a burden, and that physicians will deserve considerable help with it. However, given its failure to deal with the issue of whether the pricing of particular items is excessive, it is not clear how it expects physicians to control costs, no matter how well they are educated in evidence-based medicine, if they do not understand and cannot influence pricing. Nevertheless, the report's approach to physicians is more sympathetic and understanding of the issues physicians face than much of what has been written about health care policy</li></ul>All in all, this is a thoughtful work that deserves careful reading and response.

An Interesting Report from Boston University on Controlling Health Care Costs

An interesting report on entitled "Health Costs Absorb One-Quarter of Economic Growth, 2000 – 2005" from the Boston University Sc...

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UC faulted for paying millions in bonuses

These are private-industry-level bonuses. One can argue that such bonuses are needed to retain top talent, but teaching hospitals do not have the income of, say, A Hewlett-Packard, IBM or Pfizer. Do teaching hospitals needs to rethink their executive compensation? I'll bet most line clinicians and patients would agree. -- SS Excerpts: The University of California gave nearly $2.4 million in bonuses to 65 top executives at its five teaching hospitals in 2004, with 11 administrators receiving more than $50,000 each. The bonuses averaged $36,000 and reached as high as $82,000, according to a report to the UC Board of Regents that was made public Wednesday by an employee union. ... the largest bonus went to UC Davis Medical Center chief executive officer Robert Chason. It totaled $82,000 -- 20 percent of his annual salary of $410, 000. At UC Davis Medical Center, 12 health care executives shared bonuses totaling $526,803. At UCSF, chief executive Mark Laret received a $79,495 bonus, 18.3 percent of his $434,400 salary. The bonuses for UCSF executives totaled $583, 740. "At every level of our organization, UCSF Medical Center strives to compensate its employees at the median of the market," Laret said in a statement released Wednesday. "UCSF Medical Center leaders receive their compensation in two parts -- a base salary plus an at-risk incentive based on performance. At this time, including both parts of their compensation, UCSF Medical Center leaders are paid well below the market for comparable academic medical centers." According to university documents, the bonuses were approved in October by UC President Robert Dynes and were outlined to the Board of Regents last month. The regents did not discuss the payouts publicly, and one reached Wednesday said he objects to the bonuses. "I am very disappointed with the bonuses that UC has given its health care executives," said Regent Ward Connerly, whose term on the board expires March 1. "There is a pattern of indifference among some of our more elite people at UC to the plight of our lower-paid employees and to the appearance that some of these bonuses are obscene. This indifference is not confined to health care executives." ... Medical center workers say the bonuses are a slap in the face. Many have gone without raises for several years and are anticipating salary increases of just 3 percent this year. "They keep telling us how little money they have ... but they always seem to have money for people they want to give raises to, and it always seems to be people at the top," said Jeff Cox, a lead building maintenance worker at UCSF. "It says that I don't matter. It is hurtful." ... "We think that the money could have been better spent on patient care and low-wage workers and maintaining the quality of services," said Faith Raider, a union spokeswoman. "We have seen a lot of cutbacks in staffing and services, and we think this money could have gone to that." Jennifer Lilla, president of the University of California Student Association and a biomedical sciences graduate student at UCSF, said the money also could have been used to offset cuts in student aid. "That is half of the money we are trying to get returned to the financial aid pool,'' Lilla said. "Yes, it made a difference in a handful of people's lives, but it could have made a difference in literally thousands of students' lives had it been diverted elsewhere.''

UC faulted for paying millions in bonuses

These are private-industry-level bonuses. One can argue that such bonuses are needed to retain top talent, but teaching hospitals do not hav...

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