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Challenges at the Intersection of
I.T. and Health Care

The sound of flowing blood gushed in unison with the rhythmic undulations of the histogram on the computer monitor as it made its way through three different heart valves, one normal, one leaky and one artificial. “We’re forming a company to do away with the traditional stethoscope,” Dr. Robert Kormos explained as the video image played on the wall monitor. “It's much harder to train someone to detect a slight difference in sound than to show them the difference in a chart.”


Kormos, who among other distinguished positions, serves as Director of UPMC’s artificial heart program, has formed a company to market the device that produced the audio-video display. “If a doctor listens to a patient’s heart this week and three weeks from now another doctor listens, the second one doesn't know what the first one heard. There’s no objectivity. It's not recordable. It's not reproducible between physicians,” he continued. “The image produced by this device removes that subjectivity, standardizes the information, makes it recordable and makes it portable between physicians.”


Kormos’s answer to the stethoscope’s recordability and portability limitations is emblematic of the health care industry’s information management quandary today: that of dealing with voluminous amounts of data produced by new medical devices with an antiquated medical information system.


“We are using 21st century medicine with 19th century information technology,” said Jay Srini, formerly Chief Innovation Officer at UPMC Insurance Services, presently, Chief Strategist at Carnegie Mellon’s SCS Ventures. “With things like fMRI (functional magnetic resonance imaging), we are as advanced as we can be in terms of medical device technology. But if you look at a hospital or physician's office, things are still done on paper.”


Given the tremendous influence that electronics has had on medical devices, it is bewildering that health care information technology lags so far behind its hardware-driven counterpart; even more so because the practice of medicine is largely a matter of information exchange. Patients telling doctors where it hurts; doctors telling nurses what to do; nurses inquiring about a patient's drug allergies; pharmacists filling written prescriptions - all qualify as information exchanges. Given the abundance of good reasons for the health care industry to adopt the most advanced information technology systems available, why has it failed to keep up?


The reason is simple: It doesn't make financial sense for physicians to invest in technology that will put them out of business. Regrettably, that's what the current business model does: The more patients a doctor sees, the more money he or she makes. So why invest in technology that will make patients healthier and reduce capacity utilization?


Srini calls the present economics in the health care system perverse. “There is a dichotomy between medical equipment technology and health information technology,” she said. “On the medical technology side, doctors buy equipment to improve outcomes and also generate profits, so the economics are normal. But with information technology, if a doctor puts in an electronic information technology system, quality goes up due to fewer errors and less duplication, which is great. But who gains from it? The employer gains due to increased productivity. The insurance company gains because they won’t accidentally pay a bill twice. The consumer gains due to a better quality of life. But what about the doctor? His productivity and revenues go down because payment models have yet to evolve to embrace pay for performance rather than utilization. We are asking doctors to invest in a technology that will cause their incomes to go down. That is the perverse equation of health care technology."


The consequences of this "perverse equation" are more than meet the eye. The current system’s inherent disincentives to the adoption of health care information systems coincidentally obstruct opportunities to improve patient care and reduce health care costs by means of a more efficient system that utilizes patient information in a much more dynamic way than at present. A comprehensive patient information system, known in the health care industry as an Electronic Health Record (HER), is a complete, secure, digital record of a patient's health history. Although HER systems have been adopted by some large hospitals, and physician practices, very few small hospitals and doctor practices have invested in them. Med 3000 Chief Medical Information Officer, Jay Anders, points out that “between 40 and 50 percent of physician practices with more than 75 doctors have HER systems, while only 15 percent of smaller practices have them. That’s where the market really is.”


HER's extraordinary ability to collect, store and provide information as needed, promises to favorably impact the problem of escalating health care costs by facilitating a sea change in the way physicians work, from seeing patients in the office to non-visit based care.


“Because a majority of the serious complications of chronic illnesses for which patients see doctors are avoidable by means of patients learning about and sustaining healthy behaviors, large opportunities exist for improved patient health without the cost of a doctor’s visit. Some of the opportunities are remarkably low-tech.


“This is not rocket science,” said Dr. Michael Dunn, Associate Chief for Translational Research at UPMC, who works with the University of Pittsburgh's Diabetes Institute to promote preventive care of the disease. “There are six or seven well-known preventive care measures that diabetic patients can take in conjunction with their caregivers to control the disease and save on average, $2,500 a year in health care costs compared to someone who does not,” he said.


The Diabetes Institute’s prevention program employs wellness coaches who contact patients with blood sugar control issues on a regular basis by telephone. “It turns out that the cost of incentives amount to only about 10 or 15 percent of the cost savings that result from preventive care,” Dr. Dunn said.


While ideas like remote patient monitoring and wellness coaching are simple and cost-effective, incentives for doctors to incorporate them into their practice regimens are non-existent because, under the present system, doctors are paid for patient visits, not for patients who stay home and take care of themselves. What is more, because the typical office visit takes less than 10 minutes, doctors simply don't have time to explain the behavioral measures necessary to affect an improvement in a patient's health. And the reason they don’t have time, is that there is currently no way for them to get paid for it.


In addition to its obvious drawbacks, the perverse equation also creates an obstacle to general health improvement because the absence of patient information that would be available in a patient's HER makes it all but impossible for physicians to engage in preventive medicine, which calls not only for information about the patient they are seeing at any given moment, but also about the all the available options, diagnostic, pharmaceutical, therapeutic and behavioral. The combination of hundreds of tidbits of pertinent medical information about a single patient and a mind boggling array of possible treatments, make it extremely challenging for a physician to produce an accurate diagnosis and prescribe an effective regime of therapy, especially in less than the average eight or nine minute office visit. This conundrum leads logically to the idea that physicians might benefit from a modicum of help in treating their patients.


The issue was first addressed by the federal government several years ago with the Physician Quality Reporting Initiative (PQRI) which offered financial incentives to health care providers who adhered to specified reporting standards, including HER systems, for Medicare, Medicaid and SCHIP reimbursements. The promise of HER is large enough that Congress budgeted $19 billion in incentives under the American Recovery and Reinvestment Act’s HITECH program for the purchase, installation and proven use of HER systems. The incentive program uses both a carrot and a stick to encourage adoption of HER systems. Between now and 2015, health care enterprises will receive incentive bonuses for adopting HER technology systems. After that date, those who do not adopt the technology will receive lower Medicare reimbursements.


PQRI anticipates and facilitates a forthcoming shift in the business model for health care practices from pay-per-visit to pay-for-performance. The path flows logically from physician quality reporting, as mandated in PQRI, to evidence-based medicine, to outcomes-based medicine, to best practices protocols, to preventive health care.


Evidence-based medicine represents a departure from the customary physician practice of basing diagnoses and prescriptions on immediate clinical experience. The new, more far-reaching method entails the assessment of all relevant data, including the patient’s symptoms, verbal reports and tests, the physician’s examination and clinical experience as well as reference to the relevant professional literature, to determine the most favorable course of treatment. Following logically from evidence-based medicine, outcomes-based medicine, as its name suggests, follows the results of treatment and rewards physicians based on successful patient outcomes rather than office visits. Tracking patient outcomes logically leads to the establishment of best practice protocols. The creation and integration of de-personalized disease, therapy and outcomes data bases could facilitate the implementation of best practices databases that would positively affect the health of the nation. In turn, best practices logically lead to the practice of preventive medicine. The overall economic result is a shift in the health care provider compensation model from paying for services without regard to outcomes to paying for performance, with outcomes being the principal criteria: From fee-for-service to pay-for-performance.


If the picture appears to be rosy, it is not without its blemishes. One of the most difficult problems today is the superabundance of patient information available to doctors, much of which is superfluous.


“You get a page and a half of lab results which, except for the red flags, I'm not interested in,” Dr. Kormos said. “Instead of saying all labs are normal except one, I get 89 reports. It's just noise. One of the biggest issues in merging IT with health care is pulling out the critical issues from the background noise.”


Michael Finke, CEO of M-Modal in Pittsburgh, has seized upon the noise problem as an opportunity for his company. M-Modal transforms the tedious chores of dictation and transcription into an HER by means of proprietary voice recognition and speech-to-text software. “Right now 60 percent of all the information in medical records is kept in text records that nobody can interpret,” Finke said. “We are turning dictation directly into something meaningful by creating documents that can be mined to improve health care quality. We're putting the patient’s entire medical record into one interpretable mini data base that can be utilized across all health care systems.”


All M-Modal service transactions take place in the Internet cloud. Clients, which include 800 hospitals and health care systems, pay by service usage. For security purposes, each HER is co-located on several remote servers.


“The issue is not whether everybody should have electronic medical records,” Finke continued. “The big issue is to make it easy enough to enter data into the medical records for physicians to adopt it. The idea of having a transcriptionist input the information into a computer just doesn't fly because it interferes with the day-to-day operation of the doctor's business. We're trying to make it easy for doctors by automatically turning their dictation into a full structured and encoded document. That means we create more than just plain text, we interpret what the doctor said. We note what medications he ordered, what evidence he reported, any special patient conditions, such as smoking.”


To guard against misinterpretation either by computers or people, M-Modal employs a software technology, called natural language understanding, which makes sense of dictated reports, and standard medical vocabularies, which ensure that a term’s meaning is not misconstrued when traversing computer systems. “Instead of just having the words, we develop a linkage between what the doctor said and what it means, so that now the information provided by the physician can be acted upon by any health care professional. Every document ends up being a little database so to speak. And the collection of all the dictations becomes the medical record.”


Given the complexity of the physician’s impending outcomes-based task, it is clear that electronic health records will soon be an essential tool for the successful practice of medicine. Taking a full-practice management approach to the problem, the software-as-service company, Med3OOO, provides integrated business management and patient care services for both physician practices and hospitals. “The breadth of medical knowledge is so hard to keep up with that it soon will be impossible without assistance to make sure the diagnosis and treatment is correct and up to date,” Med3OOO Chief Medical Information Officer, Dr. Jay Anders said. “There is a lot of variability in medicine and there are best practices. But, the only way to do it is with electronic health care. Today, pay for performance is in its infancy. But in five years, doctors will get paid based on outcomes. If a patient is not improved the doctor will have to present a good reason why. Med 3OOO can help because we can manage a practice down to the point of identifying disease risk factors for small subgroups of patients, contact the doctors who treated them, and put the patients on close monitoring. We are uniquely positioned to bring in all the operational and managerial systems together so that doctors can manage both their patients and their businesses.”


“Our region is the perfect place to grow Healthcare Information Technology (HIT) companies,” John W. Manzetti, President and CEO of the Pittsburgh Life Sciences Greenhouse (PLSG), said. “The strength of our healthcare and medical institutions, university research and sophisticated technical community converge to create the perfect place for this type of innovation to go from concept to commercialization.


“The combination of healthcare with technology will give rise to a ‘smarter’ health care system that has increased efficiency, reduced errors, better quality outcomes and better patient care – ultimately save lives,” Manzetti continued.


While finding ways to manage information effectively is a topic of great concern to the health care industry, the device side of the health care/information technology picture continues to make progress, especially in the practical application of advanced technologies. For instance, Blue Roof Technologies in McKeesport has built a new home fitted with more than 100 sensors, processors, video cameras, monitors, and speakers to improve the quality of life for its occupants. Designed principally for people with disabilities, including geriatrics, the Blue Roof Research Cottage remotely monitors occupants via the Internet, thereby reducing the need for personal care. Pressure sensors in chairs, floors, showers and beds indicate whether or not occupants are active.


CO2 sensors detect how many people are in a room. Switches on kitchen cabinet and appliance doors tell if occupants are cooking and eating. A medication management system reminds occupants to take their pills via the built-in sound system, indicates which to take by illuminating the appropriate dispenser in the refrigerator, and instructs them not to take a second dose, if they forget. In addition to building assistive homes, Blue Roof has modularized its system to make it portable. Right now a pilot health monitor kiosk, designed to automatically take residents’ vital signs, is functioning in an Oakland apartment building.


Electronic health care has arrived. Soon it will be everywhere.


This article first appeared in TEQ. You can read the original at: http://www.pghtech.org/news-and-publications/teq/cover-article.aspx?Article=2010

©Copyright 2010 Thomas P. Imerito/ dba Science Communications

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