Public Health Experts Need to Reclaim the Phrase “Preventive Medicine”

“Preventive medicine” is a hot phrase in discussions of health reform. If we just get more people (why not everyone!) screened we can find disease early and save money by attacking these diseases before they become serious and expensive.

But this use of  ‘prevention’ is expensive. Or said another way: There’s a lot of money to be made in this kind of ‘prevention’.

True preventive medicine prevents disease: Reducing airborne particulate matter and pollution prevents incidence of asthma. Funding schools to provide healthy meals prevents childhood obesity. Eliminating the use of lead in paint prevents abnormal development in exposed children.

We must recognize that health screening technologies are not tools to prevent disease; rather, they are tools of early detection of disease. In a sense they define disease. Indeed as screening tools increase in specificity, the thresholds in defining disease status follow in their specificity. Certainly, early detection may give the upper hand to the patient and provider who can implement treatments that reduce the likelihood of that condition becoming life-threatening. But do all abnormalities warrant medical intervention?

Screening technologies such as MRIs are become increasingly sensitive to discovery. In his book How Doctors Think, Jerome Groopman, M.D., cites a physician: “The hateful part of MRIs – I mean they can be a wonderful technology – but they find abnormalities in everybody.” No doubt, part of the rise in the number of chronic conditions can be attributed to our increased ability to find abnormalities, even though not all abnormalities may warrant a medicinal response.

Screening tools do not and cannot prevent abnormalities. They can only find abnormalities.

The primary driver of health care costs is medical technology. Earlier detection coupled with expensive (yet often unproven) interventions have reduced mortality while increasing morbidity. Indeed, many diseases which even 15 years ago would have been a death sentence have now become manageable chronic conditions (HIV/AIDS is an obvious example). This is a testament to our ability to innovate and develop life saving technologies.

Simultaneously, technology has improved our ability to detect ‘disease’ while ensuring chronic care management through pharmaceuticals and/or invasive intervention through biopsies and more. Today, more than half of all Medicare beneficiaries have more than 5 chronic conditions. Soon it will not be uncommon for the bulk of Medicare beneficiaries to have eight or even ten chronic conditions.

One article published in the New England Journal of Medicine notes:

The demands of the public for definitive wellness are colliding with the public’s belief in a diagnostic system that can find only disease. A public in dogged pursuit of the unobtainable, combined with clinicians whose tools are powerful enough to find very small lesions, is a setup for diagnostic excess… Clinical medicine can only say, “With the methods we used, we found none of the diseases we looked for.” No one can measure the absence of all disease. (emphasis mine)

The unfortunate reality is that it is possible to over ‘prevent’ (to use the expensive version of the word). What is needed is not a halt on innovation nor a moratorium on technology. Rather what is needed is a conscious assessment as to when to screen and when treatment is necessary.

The decision as to when to do what should be made between physician and patient, but information is needed to build suggestive guidelines. Health IT, allowing for the aggregation of (anonymous) data, can help.

Can Health IT Save Health Care?

Adding health IT to our current system and claiming that will solve our health care problem is like taking a 1971 Ford Pinto and giving it a new paint job and sound system. It looks cool. It sounds cool. But you’re missing the point.

Health IT can be and should be a piece of the health reform puzzle. And it’s one of the few- and perhaps the only puzzle piece that holds bipartisan support. Even accounting for the initial upfront costs, health IT is touted to save billions of dollars. (And recent new argument: It’ll create jobs.)

This CBO report lists how health IT can:
• Eliminate the use of medical transcription and allow a physician to enter notes about a patient’s condition and care directly into a computerized record;
• Eliminate or substantially reduce the need to physically pull medical charts from office files for patients’ visits;
• Prompt providers to prescribe generic medicines instead of more costly brand-name drugs; and
• Reduce the duplication of diagnostic tests.

In addition to the above mechanisms to cut wasteful care given, there is very little doubt that health IT can improve the quality of care given. From that same CBO report, health IT can:
• Remind physicians about appropriate preventive care;
• Identify harmful drug interactions or possible allergic reactions to prescribed medicines, and
• Help physicians manage patients with complex chronic conditions.
• All problems cost money to fix, so preventing these problems from occurring does save money.

In public circles, the common rhetoric is that this higher quality of care results in lower costs. And this is where I take issue.

Yes, healthy people cost less. If you don’t need a doctor, you don’t cost much (duh). But healthy people don’t undergo high quality care; they don’t undergo any care!

On the other hand, by definition, those with chronic conditions are in constant need of care. High quality care to this population means doing more tests and providing more care more often.

That’s because only 56% of those with chronic conditions receive the recommended level of care. So higher quality care means more care. And in our system built on a la carte financing, more care means more money. Now this a real problem!

Those with one or more chronic condition currently make up 75% of our health care costs. And that number will only rise. (Explaining why is a whole other post)

Health IT can help providers know what care needs to be provided in order to adhere to these standards. Many EMRs in place today force providers to go through check-lists while caring for a patient to ensure that everything that is ‘supposed to be done’ is in fact done. EMRs also allow providers to be proactive and give patients appointment reminders to increase quality (and quantity) of care.

Does this mean we should forgo implementation of health IT? Of course not! Health IT can help us reduce needless spending for needless care and increase needed spending for needed care. It’s just that in weighing these two, spending may prevail.

Health IT is a powerful tool. But we have to recognize its place among other tools on the tool belt.

HIT/Privacy Timeline from Stimulus Bill

From Dr. John Halamka, CIO of CareGroup Health System in Boston, MA (original post here: The Timeline for ARRA Privacy Provisions), a bookmarked PDF-version of the American Recovery & Reinvestment Act that highlights sections relevant to HIT & privacy: http://ecommons.med.harvard.edu/ec_res/nt/A3B4A28D-987B-4271-B003-5A877B4F4E38/arrabookmarks.pdf

The rough timeline is below:

Upon enactment (February 16, 2009)

• Application of new tiered civil penalties based on the nature of HIPAA violations, up to $50,000 per violation and an annual maximum of $1.5 million (Section 13410)
• Enforcement by State Attorney Generals for offenses occurring post enactment (Section 13410e)

Within 45 days of enactment (April 3, 2009)

• Appointment of HIT Policy Committee members (Section 3002b)

Within 60 days of enactment (April 18, 2009)

• HHS Secretary will issue guidance on methodologies and technologies that render information unreadable (Section 13402)

Within 180 ays of enactment (August 16, 2009)

• HHS and the Federal Trade Commission will promulgate interim final regulations on notification of breaches. The FTC rules will apply to breach notification by PHRs that are not covered by HIPAA or Business Associate agreements (Section 13402, 13407)

By December 31, 2009

• HHS must adopt through rulemaking the initial prioritized set of standards which should include the accounting for disclosures (Section 3002b)

Due within one year post enactment (February 17, 2010)

• The Secretary will appoint a Chief Privacy Officer (Section 3001)
• The Office of Civil Rights and HHS will launch an education initiative to improve public transparency on the use of health information (Section 13403)
• The Government Accountability Office will report on best practices for disclosures for treatment and use of electronic informed consent (Section 13424)
• HHS will report on and provide guidance on de-identification (section 13424c)
• Covered entities must enter into Business Associate Agreements with PHRs, HIEs, and other services that handle projected health information (Section 13405e)
• HHS will issue rules on opting out of fundraising solicitations (Section 13406)
• HHS will report on guidance on the effective technical safeguards for carrying out the HIPAA security rule (Section 13401c)
• HHS and the Federal Trade Commission will report on privacy and security requirements for PHR vendors and applications

One year post enactment (February 17, 2010)

• HHS and the Office of Civil Rights clarify application of criminal penalties for non-covered entities (Section 13409)
• HHS to issue rules on which entities are required to be business associates (Section 13401)
• Right to restrict disclosures to health plans for services paid for out of pocket (Section 13405a)
• HHS Secretary required to conduct periodic audits of entities covered by HIPAA (Section 13411)
• Right of electronic access of records by patients takes effect (Section 13405e)

Within 18 months of enactment (August 17, 2010)

• HHS guidance on minimum necessary data (Section 13405c)
• Regulations regarding sale of data prohibition which take effect 6 months post promulgation (Section 13405a)

By 2011

• Initial deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired after January 1, 2009 (Section 13405c)

24 months post enactment (February 17, 2011)

• Clarification of ability to pursue civil penalties when criminal penalties are not pursued (Section 13405)

By 2012

• Regulations for methodology for distributing penalties or settlement money to harmed individuals (Section 13410)

By 2013

• Extended deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired after January 1, 2009 (Section 13405c)

By 2014

• GAO will report on the impact of ARRA (Section 13424)
• Initial deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired before January 1, 2009 (Section 13405c)

By 2016

• Extended deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired before January 1, 2009 (Section 13405c)

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A sustainable business model for health information exchange

Personal Health Records (PHRs) have received a lot of attention lately with the release of Google Health and Microsoft HealthVault. PHRs allow individuals to securely organize their own health information and to control who has access. PHRs allow users to import data from many large repositories, including insurers, pharmacies, and laboratories, but mostly do not connect to care providers, excepting a few integrated delivery networks such as Kaiser and Beth Israel in Boston.

RHIOs are less well known but have been around much longer. RHIOs exist at the community level to facilitate the exchange of health information between care providers (e.g. doctor notes), though some also aggregate data from insurers, pharmacies, and labs. The primary audience here is care providers, rather than consumers. In theory, a network of RHIOs could form together to create a National Health Information Network (NHIN), but this is unlikely to occur without significant federal funding. More than 140 RHIOs exist today, but only a handful are considered sustainable (look at the Regenstrief Institute and MA-SHARE). Interoperability between EHR systems is complex and expensive, and though it will improve quality of care, there will be a negative return on investment until a significant proportion of providers is sharing data in a standardized way. Read The State Of Regional Health Information Organizations: Current Activities And Financing by Julia Adler-Milstein, et al for a better understanding of the current RHIO landscape.

Given the similar goals of PHRs and RHIOs, I have speculated that these ideas may eventually end up merging. John Halamka, CIO of Harvard Medical School, commented on Google Health’s new sharing and auditing features in his Cool Technology of the Week update:

I’ve already invited my primary care doctor, my family, and a few of my clinical systems colleagues who built the BIDMC-Google interface. Thus, in one morning I’ve become my own regional health information organization, sharing medical records across multiple organizations with perfect privacy controls.

However, Dr. John Glaser, CIO of Partners Healthcare, estimates that only 1 out of 10 American’s with access to an electronic health record will access it, meaning that consumers are unlikely to drive the healthcare industry’s to adoption of EHR and HIE (see Glaser’s interview with Information Weekly).

Though PHRs do not have a huge chunk of the health consumer market, 6 million users (10% of the estimated 60 million American’s with electronic health records) is large enough to give Google, Microsoft, Dossia and Revolution Health some leverage with data furnishers. PHRs also capture a monetizable audience (consumers) whether through advertising or sales of health applications. RHIOs, on the other hand, make participating providers pay to use their service, but are not large enough to offer providers significant incentives for involvement. Most rely on government funding to stay afloat. I am of the opinion that unless government steps in to fund a largescale network, PHRs have settled on a more sustainable business model and could more easily extend their data aggregation efforts into doctors notes and other administrative data handled by RHIOs. In this case, both providers and consumers would be the primary audience of the platform. By using the PHR for both consumer and clinical needs, the record becomes immensely more useful, assuming that audit trails, quality control, and security measures are in place.

What is an EHR?

There is actually a lot of discussion still taking place about what an electronic health record (EHR) actually is. Earlier this decade, a survey taken at a convention of EHR vendors and hospitals estimated EHR adoption at 60%. This information was used by the Bush administration in 2004 to justify formation of the Office of the National Coordinator for Health IT (ONC) and to set the goal of 90% of Americans having electronic health records by 2014. One decade seemed reasonable given the 60% adoption rate. We now know that the adoption rate among hospitals is closer to 10%, with 10-25% currently in planning or implementation stages.

Part of the problem is in the definition. The survey simply asked if care providers had electronic records. But that could mean patient information, a billing and claims system, electronic order entry, or any number of things. The Institute of Medicine released a report in 2003, Key Capabilities of an Electronic Health Record System, that attempted to solve this, and identified the following core functionalities of EHR:

1. Health information and data
2. Results management
3. Order entry/order management
4. Decision support
5. Electronic communication and connectivity
6. Patient support
7. Administrative processes
8. Reporting and population health management

The 4 in bold might be considered the bare minimum. Administrative processes are certainly important to the operations of a hospital, but these are historically separate systems focused on billing and insurance claims. Oddly enough, evidence has shown that providers that initially adopt electronic billing systems are no more likely to adopt EHR than those without it. Treating electronic billing as a first step, then, doesn’t work.