The Economics of Electronic Medical Records

As a big believer in the efficiencies gained by technology appropriately implemented, I always find it shocking that medicine seems so far behind the curve in terms of electronic medical records (EMR). Most doctors agree that EMRs are beneficial, yet a recent report found that only 1 in 5 doctors have them in their practices:

The report, published online on Wednesday in The New England Journal of Medicine, found that doctors who use electronic health records say overwhelmingly that such records have helped improve the quality and timeliness of care. Yet fewer than one in five of the nation’s doctors has started using such records.

Bringing patient records into the computer age, experts say, is crucial to improving care, reducing errors and containing costs in the American health care system. The slow adoption of the technology is mainly economic. Most doctors in private practice, especially those in small practices, lack the financial incentive to invest in computerized records.

At first, I was disappointed and wanted to blame the doctors for not biting the bullet and paying for EMRs looking at it as an investment. But, the more I considered it, I can't blame them. If it were my practice, and the implementation costs of EMR were in the tens of thousands of dollars, I might hold off as well. I know I am over-simplifying this, but an EMR is really just a fancy, specialized database. Databases are ubiquitous in business. Clearly, the costs of implementing one cannot really be that high across the system.

The problem, as in many other situations in U.S. healthcare, is the lack of centralized, standardized solutions. Honestly, this can be either through the U.S. government or through free markets. Either the government should provide incentives, perhaps tax credits, for physicians to implement EMRs (heck, even low or zero interest loans, whatever). Or, the free market should step in and provide a low-cost solution that becomes the de facto standard for EMRs. To some degree, Google and Microsoft are already doing this, but their approach is more patient-centric isntead of practice-centric. What medicine needs is a "patient OS", much like how Microsoft Windows became the standard platform for PCs. With a patient OS, there would some default format for EMRs making it easy for offices even with different implementations to communicate with each other. If the basic patient data is defined in this open standard .emr format, then it would be easy for groups to implement modules for particular specialties (like, the results of p-thal tests in cardiology or something). Patients benefit, doctors benefit:

Dr. Masucci was already using Athenahealth’s outsourced financial service, and less than two years ago adopted the online medical record.

Today, Dr. Masucci is an enthusiast, talking about the wealth of patient information, drug interaction warnings and guidelines for care, all in the Web-based records.

“Do I see more patients because of this technology? Probably no,” Dr. Masucci said. “But I am doing a better job with the patients I am seeing. It almost forces you to be a better doctor.”

At the end of the day, this just shows the lack of leadership within medicine as a whole, which is why doctors end up getting squeezed by service providers as well as by insurance companies. Sad, really. Today's reality is doctors lose and patients lose.

I'm not really this pessimistic. Read the next, hopefully happier post! Subscribe to Scrub Notes by email or in a reader!

41 Secrets Your Doctor Would Never Share

Apparently, we doctors (or future ones) have a lot of secrets we don't share. Well, I'm going to share them anyway. Some choice ones include:

Your doctor generally knows more than a website. I have patients with whom I spend enormous amounts of time, explaining things and coming up with a treatment strategy. Then I get e-mails a few days later, saying they were looking at this website that says something completely different and wacky, and they want to do that. To which I want to say (but I don't), "So why don't you get the website to take over your care?"
--James Dillard, MD

Nooooo! Don't tell them our secret!

In many hospitals, the length of the white coat is related to the length of training. Medical students wear the shortest coats.
--Pediatrician, Baltimore

The sad reality of modern medicine in America:

Not a day goes by when I don't think about the potential for being sued. It makes me give patients a lot of unnecessary tests that are potentially harmful, just so I don't miss an injury or problem that comes back to haunt me in the form of a lawsuit.
--ER physician, Colorado Springs, Colorado

The article is pretty short, has more good quotes, and some interesting/shocking statistics at the end. For more about how doctors think, check out Jerome Groopman's excellent book. Enjoy!

Updated 2015-12-13

Internet Addiction is a Disease. No, Really.

Apparently, internet addiction has been nominated for entry into DSM V:

First, we all had mild Asperger's. Now, Internet addiction disorder? Give a geek a break. In the March issue of the American Journal of Psychiatry, Jerald Block proposed that Web abuse be added to his field's bible, the Diagnostic and Statistical Manual of Mental Disorders. Block cites research from South Korea, where, he says, the affliction is considered a serious public health problem, and the government estimates that 168,000 children may require psychotropic medications. In China, the Beijing Military Region Central Hospital puts the number of teenage pathological computer users at 10 million.

I have mixed feelings about psychiatry. On the one hand, it was a generally chill rotation and I had a pretty good time. However, the field itself seems to be just barely scratching the surface of truly treating patients. Compared to say, oncology, psychiatry seems to lump people together and treat symptoms in a broad way, without truly addressing the underlying problems. Sure, there is the biopsychosocial formulation, but in reality, only the 'bio' gets treated while the social problems generally tend to fester. I certainly do not have any solutions, but the whole situation just strikes me as sad. I think over-medicating is a significant problem, and one that psychiatry does little to address given its own dependency on pharmaceuticals, relative to other fields.

This dependency leads to ridiculousness as described above. Why categorize this as a separate addiction? The goal here is to be able to get reimbursements from insurance companies for treating this as well as specific indications for certain drugs to treat this as well. If one thinks about it, there really shouldn't be any underlying distinction between Internet addiction vs. other forms of socially-derived addictions. What next, Dungeons&Dragons addiction? Unlike addiction to a substance, which does induce actual biological changes, it's not clear to me how the internet differs from an addiction to gambling, shopping, or other self-destructive behavior.

Psychiatrists! What'll they think of next? =)

"The Russert Effect" in Cardiology?

I have no real good reason for not posting recently, but we'll just say it was my summer break...

Sadly, during that time, the moderator of 'Meet The Press' Tim Russert passed away. He was a relatively unique celebrity, even among the news media types. My connection to him was that he was one of the two speakers at my college graduation, speaking at Class Day. He has been widely eulogized, but for my own little part, I always admired his passion for his profession.

As people absorbed the news and began to reflect on it, many were struck by the suddenness of it all. I imagine it sparked debates in my households, much as it did at my house. My dad strenously argued that Russert was grossly out of shape, and thus, this shouldn't be much of a surprise. While I agree he was overweight, it was still shocking to me to see someone who wasn't truly morbidly obese, still "young" relatively, and leading an active life with no known CAD symptoms to die like that.

The discussion prompted me to do some reading. While I had heard this before, the event really drove home the point that cardiology is still far from truly understanding how plaques rupture and how to predict this:

Clearly, there was sorrow for Mr. Russert’s passing, but also nervous indignation. Many people are in the same boat he was in, struggling with weight, blood pressure and other risk factors — 16 million Americans have coronary artery disease — and his death threatened the collective sense of well-being. People are not supposed to die this way anymore, especially not smart, well-educated professionals under the care of doctors.
Mr. Russert’s fate underlines some painful truths. A doctor’s care is not a protective bubble, and cardiology is not the exact science that many people wish it to be. A person’s risk of a heart attack can only be estimated, and although drugs, diet and exercise may lower that risk, they cannot eliminate it entirely. True, the death rate from heart disease has declined, but it is still the leading cause of death in the United States, killing 650,000 people a year. About 300,000 die suddenly, and about half, like Mr. Russert, have no symptoms.
Cardiologists say that although they can identify people who have heart disease or risk factors for it, they are not so good at figuring out which are in real danger of having an attack soon, say in the next year or so. If those patients could be pinpointed, doctors say, they would feel justified in treating them aggressively with drugs and, possibly, surgery.

Having worked with a cardiologist as a preceptor the past few months, I myself kind of felt that a coronary angiogram may have caught this, but angiograms have their own risk and Russert seemed to be truly asymptomatic, if not clearly healthier than he was a year ago. Given this outcome, I wonder whether this will motivate more people to get a check up, or whether people will view this as a failure of medicine and be more averse to wasting their time / money on something which they believe has little predictive value.
A few years ago, Katie Couric lost her husband to colon cancer. She famously went on air to do a live colonoscopy for the Today Show in an effort to increase awareness of colon cancer screening. Researchers studying trends later on noted a significant change in people's behavior, which they dubbed the "Couric Effect" for gastroenterology. Only time will tell what the "Russert Effect" will be on cardiology.

Don't miss a post! Subscribe to Scrub Notes by email or in a reader!

Back to the Future

A recent article posits that our brain has an underlying mechanism behind all optical illusions, namely, the ability to see into the "near" future:

In the current issue of the journal Cognitive Science, researchers at the California Institute of Technology and the University of Sussex argue that the brain’s adaptive ability to see into the near future creates many common illusions.

“It takes time for the brain to process visual information, so it has to anticipate the future to perceive the present,” said Mark Changizi, the lead author of the paper, who is now at Rensselaer Polytechnic Institute. “One common functional mechanism can explain many of these seemingly unrelated illusions.” His co-authors were Andrew Hsieh, Romi Nijhawan, Ryota Kanai and Shinsuke Shimojo.

One fundamental debate in visual research is whether the brain uses a bag of ad hoc tricks to build a streaming model of the world, or a general principle, like filling in disjointed images based on inference from new evidence and past experience. The answer may be both. But perceptual illusions provide a keyhole to glimpse the system.

Makes sense to me. For more perceptual puzzles, check out Blind Spots.

Tight Rein on Blood Sugar Has No Heart Benefits

Controlling blood sugar not helping diabetics? It's kind of a shocking headline, but there it is:

Two large studies involving more than 21,000 people found that people with Type 2 diabetes had no reduction in their risk of heart attacks and strokes and no reduction in their death rate if they rigorously controlled their blood sugar levels.

The results provide more details and bolster findings reported in February, when one of the studies, by the National Institutes of Health, ended prematurely. At that time, researchers surprised diabetes experts with the announcement that study participants who were rigorously controlling their blood sugar actually had a higher death rate than those whose blood sugar control was less stringent

Such news really goes against some of the central dogma of treating diabetes, namely that tight sugar control is paramount. As much as such research is necessary in order to figure out how to truly treat the disease, I fear that patients will get confused when they read such headlines and perhaps a few will think that they don't need to control their sugar at all. Then again, perhaps I am not giving patients enough credit.


Don't miss a post! Subscribe to Scrub Notes by email or in a reader!

Cellphones Causing Cancer?

A recent article again raises the possible link between cellphones and neurological cancers:

Last week, three prominent neurosurgeons told the CNN interviewer Larry King that they did not hold cellphones next to their ears. “I think the safe practice,” said Dr. Keith Black, a surgeon at Cedars-Sinai Medical Center in Los Angeles, “is to use an earpiece so you keep the microwave antenna away from your brain.”

Dr. Vini Khurana, an associate professor of neurosurgery at the Australian National University who is an outspoken critic of cellphones, said: “I use it on the speaker-phone mode. I do not hold it to my ear.” And CNN’s chief medical correspondent, Dr. Sanjay Gupta, a neurosurgeon at Emory University Hospital, said that like Dr. Black he used an earpiece.

Along with Senator Edward M. Kennedy’s recent diagnosis of a glioma, a type of tumor that critics have long associated with cellphone use, the doctors’ remarks have helped reignite a long-simmering debate about cellphones and cancer.

That supposed link has been largely dismissed by many experts, including the American Cancer Society. The theory that cellphones cause brain tumors “defies credulity,” said Dr. Eugene Flamm, chairman of neurosurgery at Montefiore Medical Center.

I'm not sure why, but I feel like such views are unduly alarmist. If a definitive study does not yet exist, then those who believe such an association does exist should construct a definitive study and perform the research, versus going to the media and sounding "possible" alarms. This reminds me of the news stories every year of some random natural good that either causes or cures cancer/heart disease/diabetes. For example, the research on alcohol is confusing. You should drink a glass of wine a day to prevent heart disease, but any more, and you increase the risk of liver disease and other adverse effects. I feel like ambiguous research findings should be kept out of the public arena until something definitive can be said. Unless this is done, we as physicians risk confusing our patients and losing their trust. Just my $0.02.

The Biological Basis of Sarcasm

Interesting article on how the use of fMRI's helped localize where sarcasm resides in the brain:

There was nothing very interesting in Katherine P. Rankin’s study of sarcasm — at least, nothing worth your important time. All she did was use an M.R.I. to find the place in the brain where the ability to detect sarcasm resides. But then, you probably already knew it was in the right parahippocampal gyrus.

What you may not have realized is that perceiving sarcasm, the smirking put-down that buries its barb by stating the opposite, requires a nifty mental trick that lies at the heart of social relations: figuring out what others are thinking. Those who lose the ability, whether through a head injury or the frontotemporal dementias afflicting the patients in Dr. Rankin’s study, just do not get it when someone says during a hurricane, “Nice weather we’re having.”

Apparently, this region is also lost in frontotemporal dementia, leading to a loss of understanding of social context in that disease as well.


Don't miss a post! Subscribe to Scrub Notes by email or in a reader!

What to do about Micrometastases?

Given the advance of technology and techniques, specifically sentinel node biopsy, the detection of micrometastases has increased. But this poses a problem:

“When someone has a very small amount of tumor, what is their actual risk?” asked Dr. Hiram S. Cody III of the Memorial Sloan-Kettering Cancer Center in New York. A tiny bit of cancer could mean that a tumor is going to reignite. Or it could mean very little.

The presence of these so-called micrometastases, and other wisps of tumor too small to count as full-fledged metastases, has been documented in lymph nodes for decades. But only with the popularity of sentinel node testing has the question of micrometastasis entered everyday medical practice.

“Because they are looking at fewer nodes, they can look more carefully,” said Brenda K. Edwards, associate director for surveillance research at the National Cancer Institute.

Dr. Edwards and her colleagues recently found that diagnoses of breast cancer with micrometastatic lymph-node involvement began to increase markedly after 1997 and that it shows no signs of leveling off.

So, what does one do about these findings? I suppose these are potentially false positives, but I feel like my bias is still towards treatment. The article notes that some women experience arm/axillary tightness after such biopsies, but that seems a small price to pay to reduce the risk of metastatic breast cancer. I think the question should be more explicitly framed as how to treat these findings of micrometastases, instead of the implicit "Should we treat them, or not?" Perhaps I need to read more about this, but it seems like not treating a positive finding is a dangerous road to follow without some very, very solid data.