Green, Beverly B., Andrea J. Cook, James D. Ralston, Paul A. Fishman, Sheryl L. Catz, James Carlson, et al. “Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control: A Randomized Controlled Trial.” JAMA 299, no. 24 (June 25, 2008): 2857-2867.

Our findings demonstrate the effectiveness of using home blood pressure monitoring combined with pharmacy care over the Web to improve BP control for patients with essential hypertension

This is a significant study in the world of health care and e-health - the first randomized controlled trial to test the use of care management over the Web. It was performed at Group Health Cooperative, using the Web services that I helped implement as part of our electronic health record system.

Looking at the data, it appears that patients with uncontrolled hypertension without access to supportive pharmacists over the Web were much less likely to have their blood pressure controlled compared to patients that did. In other words, patients were not able to achieve as sufficient control through doctor visits alone.

This study further supports the idea that we have a great opportunity to support non-visit-based, participatory health care as a modality to manage chronic illness.

For a health system already paying for physician visits that have less than a 1 out of 2 chance at recording a controlled blood pressure in them, maybe there’s an opportunity to change the way high blood pressure is managed, for example, in California.

Design Thinking, Tim Brown, Harvard Business Review, June, 2008

Rachel Block, the Executive Director of the New York eHealth Collaborative (NYeC - pronounced “nice” - get it?) alerted me to this article in the June, 2008 issue of the Harvard Business Review. It’s available for free on their Web site now, so waste no time in getting it.

The article is written by the CEO and President of IDEO, Inc., and talks about several projects that created value for customers using design thinking. The first project described is one at Kaiser Permanente, where, through this approach, nurses changed their rounding strategy to “at the patient’s bedside” instead of “at the nurse’s station.” This in and of itself was striking to me, because it’s exactly the approach that other national leaders in patient and family centered care are pursuing. How great that the same conclusion was reached about where nurses can best serve patients.

Beyond the great health care example, there are other examples that demonstrate the same thing:

Many of the world’s most successful brands create breakthrough ideas that are inspired by a deep understanding of consumers’ lives and use the principles of design to innovate and build value.

As Diana Forsythe discussed in her article on creating a patient education system for migraine sufferers, the most valuable innovations are the ones that understand the lives of the people they will touch, and then support those lives with the product/service/technology to make things better, rather than the other way around. To me, understanding the lives of the people that innovations touch means going to where those lives’ experience happen, and bringing the people who feel the impact into the design of the innovation.

I happen to have been to the Kaiser Permanente Garfield Innovation Center in Oakland, California (here’s a post about it and a little about its namesake, Sidney Garfield, MD), where we received a demonstration of the IDEO process underway on a project in one of the Kaiser Permanente Hospitals. I brought my most critical LEAN goggles with me to assess the process for respect for patients and those who serve them, and I was very favorably impressed. The Garfield Center is an impressive place in general, if you look at the photos in the post, or get a chance to visit yourself.

The theme of patient (and community) involvement in the design and leadership of systems has been on my mind in the next phase of work I am doing, hence these posts. I am glad that there are people like Rachel who know me well enough to add the right fuel to the fire….Enjoy the article and please post your thoughts on what it means for what you do.

DesRoches, Catherine M., Eric G. Campbell, Sowmya R. Rao, Karen Donelan, Timothy G. Ferris, Ashish Jha, et al. “Electronic Health Records in Ambulatory Care — A National Survey of Physicians.” N Engl J Med (June 18, 2008). Electronic Health Records in Ambulatory Care — A National Survey of Physicians.

This is an informative study of electronic health record penetration by the group at Massachusetts General Hospital, funded by the Office of the National Coordinator.

The news? Not very good. Only 4 % of physicians have “fully functional electronic record systems.” The numbers are even more concerning if you look at small practices, where the overwhelming majority of Americans receive care: 2 % in practices with 1-3 physicians. In other words, most American physicians use paper based medical records.

There are a few (among several) very good things that this research group has done:

1. They have defined what is meant by “electronic health record” so we can track this over time
2. They have found that there was NOT a difference in rates of adoption among providers serving minority patients, uninsured patients, or patients on Medicaid

With that in mind, here’s the hope that this brings:

1. If we’re able to define what physician access to an electronic medical record is, let’s now define what patient access to that same electronic medical record is.
2. Let’s begin to use that metric as a complement to, or instead of the physician access metric. In other words, the EHR is not really implemented unless the patients can access the data in it to manage their health and participate in their care.
3. Let’s be excited about the fact that with adoption on par among providers serving the uninsured, minority, and patients on Medicaid, that patient access to the data can become as standard for these patients, as they may become for commercially insured patients.

On the topic of the “patient access” metric - I don’t think we currently have a good definition. One organization might say, “We have x-thousand patients accessing their clinical information through a portal.” Another might say, “We have x-percent penetration of our patient base accessing a portal with their clinical information.” Yet another might say, “X-percent of chronically ill patients are accessing a PHR that contains their claim data.”

Not to bring up the “c”-word (crowdsourcing), but maybe we should get together to figure out what patients consider “access to data that allows them to fully participate in their care.”

In the meantime, thanks to the team at Mass General and ONC for tracking the physician side of things - great work as always.

"Nickel and Dimed: On (Not) Getting By in America" (Barbara Ehrenreich)

Last week, I was walking with one of my patient-centered mentors, David Sobel, MD, through one of my favorite museums in Washington, DC., The National Portrait Gallery. As I brought him to one of my favorite pieces, I asked him if he read this book, and he told me it was one of the most influential books he’s read. “Have you gotten to the Wal-Mart section yet?” he asked. I have, and I have to say I agree with his assessment.

This book preceded a more modern version of living among the corporate natives which I reviewed previously, Punching In, by Alex Frankel. Unlike Alex Frankel’s adventure, Barbara Ehrenrich goes completely native, adopting the lifestyle of a minimum wage worker, down to eating, living, and surviving (or attempting to) in several different American cities. Her jobs include being a server in several restaurants, a house cleaner for a large national franchise, and a stint in retail.

We learn some realities of these jobs - it’s never really okay to not always be doing something, even if there’s nothing to do. One of her places of employment calls this “time theft.” So there’s a constant flow to the work, some of it useful, some of it not. The profiles of her coworkers describes the conditions that the working poor must accept - not having first month’s rent and deposit may mean spending $60 a night in a motel, an irrational yet necessary way to survive. The quality of life that Ms. Ehrenrich accepts for her assignment is concerning bordering on dangerous - a single woman in an efficiency with no screen on the window on the ground floor.

As I read this with an interest in employer-based health, I also learned a lot.

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Pickering, Thomas G., Nancy Houston Miller, Gbenga Ogedegbe, Lawrence R. Krakoff, Nancy T. Artinian, and David Goff. “Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring. A Joint Scientific Statement From the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association.” Hypertension (May 22, 2008).

As we have been planning a multi-stakeholder pilot to demonstrate improved management of chronic conditions by Californians, this paper was just published, which adds compelling information to the discussion. Talk about interesting timing.

The paper is a compendium of research and information to date on the value of home blood pressure monitoring, which has not been previously integrated into the clinical practice of improving blood pressure control. The impact of poor control is reiterated: high blood pressure as accountable for 27% of total CVD events in women and 37% in men.

Useful Facts

• 35% of hypertensive patients check their BP once a week, 64% of patients own a monitor.
• Arm monitors appear to still be the best choice through validation studies.
• There is often “poor” agreement between patient reported readings and readings stored in the monitors’ memory, with one study showing up to a 20% error rate.
• Patients are at risk for over-diagnosis (”white coat hypertension”) up to 20% of the time, and under-diagnosis (”masked hypertension”) up to 10 % of the time, resulting in over/unnecessary treatment, or undertreatment.
• Blood pressures measured outside of the doctor’s office in many cases is superior in predicting which patients are at risk for organ damage.
• It appears that more study is needed regarding the effectiveness of home blood pressure monitoring to guide treatment and ultimately support better control. As far as I can tell, none of the studies mentioned here assess the impact of coupling improved patient-health system communication (eg secure messaging with physicians or health system) with home blood pressure monitoring.*
• Medicare currently reimburses ambulatory (24 hour) blood pressure monitoring for patients with suspected white coat hypertension, and this monitoring has been shown to be cost-effective in reducing unnecessary treatment.
• Of extreme interest in our planning, this paper refers to studies assessing patient attitudes toward home monitoring, which appear favorable, but maybe less so when out of pocket expense is required - this is a follow-up/countermeasure item.

*A helpful study is under way at Group Health Cooperative that is going to add very useful information to this part of the discussion.

Conclusion

Beyond information about the value of home blood pressure monitoring, there are suggested protocols for integrating this monitoring into practice. This seems like a great springboard to integrate this into patient access to their own clinical information, along with potential connections to the health system and other patients.

Based on the information presented, there seems to be a case for employing “connected” blood pressure monitoring for accurate diagnosis of blood pressure and response to treatment. Given that Medicare already reimburses ambulatory blood pressure monitoring for white coat hypertension, there may also be a case to extend, as a pilot, reimbursement for home monitoring for diagnosis and initial management of blood pressure outside of physician visits. This ties well to the data that most patients with high blood pressure are insured and seeing physicians, with only 35% control, making this approach a worthy alternative.

From a biological plausibility perspective, it makes sense that measuring an ongoing physiological state (average blood pressure throughout the day) in its native environment, over time, has a likelihood of being more accurate than a few point measurements done outside of the environment where people live and work (the doctor’s office).

The opportunity for the proposed project here is to integrate the benefits of home monitoring with a sustainable workflow inside and outside of the health system, using technology available today, to improve patient and family involvement in their care. Of interest, the Agency for Healthcare Quality and Research is promoting the idea of patient involvement in care as a quality and safety improvement strategy for patients. This work could extend the strategy to more stakeholders, including employers and the health system itself.

Conflict of Interest Analysis

I think this should be part of a review of any paper, given the information being published about sponsored research (here’s some examples).

The lead author has a significant relationship with device maker Omron, and has received speakers fees from pharmaceutical manufacturer Boerhinger-Ingelheim and Omron. Another author has received speaker’s fees from Merck and serves in a consultant/advisory board capacity for Pfizer and CV Therapeutics.

There was discussion previously about support to the American Heart Association by device makers.

These associations could result in over-exhuberant promotion of home blood pressure monitoring devices and treatment (i.e. it’s unlikely that a device manufacturer would have an interest in less devices being sold), and need to be taken into account when reviewing this piece. This might be reflected especially in areas where the data is/was equivocal about benefits, yet conclusions are framed in the positive or hopeful.

One of the issues in the discussion of device/medication promotion is that new treatments are compared to placebo instead of to current practice. The information presented here compares the treatment of interest to current practice, which has room for improvement. With that in mind, I think the information here is contributory to the work we’re considering and will be used to update the A3 accordingly.

A Disclosure of My Own

I should point out that I assisted in the planning of the Group Health blood pressure study mentioned above from an operations/informatics perspective, and was not funded under the grant and am not a co-author of that study, which is not connected to this work. I am currently funded by the California Healthcare Foundation.

Comments welcome, of course.

Brownlee, Shannon. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. 1st ed. Bloomsbury USA, 2007.

In my work guiding the development and maintenance of a Statewide electronic health record system, I used to say that a hospitalization is a devastating event for a patient and their family and should be prevented if at all possible. This book is a reminder that it truly can be.

I rented this book (more on that in another post) with the understanding that it would cover the issue of health care waste and relate to my intense interest in system accountability and transparency to patients. The first part of the book was horrifying to me because I have seen many of the examples cited with my own eyes (different patients, similar situations). The last part provided for a welcome reflection of myself as a physician, fortunate to be created and nurtured by one of the best-in-class health care systems mentioned in the book.

Scary excesses and waste in healthcare

The book begins discussing the work of Dr. Jack Wennberg, who discovered impressive differences in the way patients were treated in different regions, and the fact that the patients weren’t different, the health systems around them were. I was familiar with Dr. Wennberg’s work before, but I was not familiar with the fact that even today, his team is challenged at some level to achieve acceptance in a medical community that is rewarded for “doing more” rather than “doing right” by people. The examples of the distortion of care provision brought about by historical changes in financing are scary and realistic at the same time. I know them well and saw examples all the time; it was the environment I was trained in during medical school.

In my situation, I took a year off from medical school to attend the UC Berkeley School of Public Health. And then I began training at Group Health Cooperative, as a Family Physician. I marked Group Health as my #1 choice of residency because it seemed like a place where people were always working to do the right thing.

What a strange place it was, and in a good way - where specialists would consult with you and say, “This something that you can manage well, let me show you how,” or pharmacists would say, “You can actually prescribe this antibiotic and achieve the same result for your patient, with much lower cost.” Or when a surgeon once told me, not long ago, “I’m as interested in [informing] the 80% of patients [who are referred to me] who don’t need surgery as I am in the 20% that do.” Not a single piece of pharmaceutical paraphernalia in sight, and no discussion of drugs by their trade name, only the generic name. To this day I know very few trade names. I have never written a single prescription for rofecoxib or celecoxib.

A great read, but with some inaccuracies / cautions

The book ultimately promoted (with greater vigor) in me the feeling that we can and do things differently, that what we’ve all seen in the medical profession that seemed untoward, is untoward, and unfortunately it seems there are no stewards. I liked this quote:

…harm can only be seen in the aggregate, while the responsibility for it is diffuse

Referring to the idea that each individual actor is maximizing their own (self, and selfless) interest in a moral vacuum.

The chapter I had concern about was toward the end; throughout the book doctors seem to be alternately derided and praised, and toward the end, in the section on managed care, there was (in my mind) an unchallenged problem, which was that doctors didn’t/wouldn’t provide feedback or communicate about the best healthcare practices. The topic of medical education was also not discussed well, the idea that doctors are trained not to collaborate, to be islands unto themselves; very differently from their business administration colleagues. Finally, some of the characterization of Kaiser Permanente and (by extension) Group Health physicians as “a bunch of idealists” is a bit off the mark and superficial. If I have learned anything in my journey over the past 8 months, it is that all physicians and health care workers are idealists (my quote “everyone that goes into healthcare is exceptional; they have to be for a job this challenging), and crave a health care system that supports their energy and creativity.

The other key opportunity that I think Ms. Brownlee touched on but missed (and maybe will follow-up in another book?) is the value of patient and family involvement. The solutions she invoke include the concept of an “accountable” healthcare system, but they don’t touch on deep patient and family involvement, such as at centers like Medical College of Georgia. Health Information Technology and EHRs are referred to as physician tools only; patient access isn’t discussed. If anything, these are the true innovations of the systems that are praised throughout the book. A system that is willing to be transparent with its patients is probably more willing and able to improve itself over time.

A nice challenging look in the mirror

Despite some of the issues above, there’s a bit of courage in writing this story down, as well as in some other articles I have seen Ms. Brownlee pen online. I really believe that more we get involved in our own care, and promote that for every patient in every system, the more likely it is that the system will respond to the needs as they exist. My own heritage in one of the systems lauded throughout is affirming that doing the right thing by patients and not more of something is the right work and feels good to do. I think every physician (and patient) is capable of understanding the benefits of this, as well.

Businessweek: The Mac in the Gray Flannel Suit

This week’s cover of Businesweek appears to triumphantly announce Apple, Inc.’s comeback (sort of) into the enterprise, even if Apple isn’t actually marketing to that sector.

For Mac afficionados, this is a big change from Businesweek’s former pronunciation of near-death (see The Fall of An American Icon, from 1996, or the Apple Death Knell Counter from Mac Observer).

Okay, so Apple is back; however, the opportunity here for enterprise IT is not so much to bring on a new platform, it’s to explore more thoroughly the idea of “employee asset ownership.” I didn’t find much searching for this idea on Google (maybe there’s a more official name for this? If there is, please add it in your comments), except that a few companies like BP and Unisys are experimenting with it.


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Kemp EC, Floyd MR, McCord-Duncan E, Lang F. Patients Prefer the Method of “Tell Back- Collaborative Inquiry” to Assess Understanding of Medical Information. J Am Board Fam Med. 2008;21(1):24-30. [Accessed April 17, 2008].

One of my patient centered health-care mentors, David Sobel, MD, from Kaiser Permanente passed this study on to me in the context of work we are exploring in the area of self management. Since I haven’t mentioned David on this blog before, I’ll point out that his impact in my career and many other health care professionals has been significant. David is the physician that taught me that the primary care giver is the patient (and their family, community). Because of this, when I think of “medical home,” I don’t think of the primary care provider’s office. I think of the true medical home, the place where the patient lives, works, and plays (with their family and community).

I digress, but back to the article, it puts together the call to action to involve patients and families in their care, before they leave the exam room.

First, the paper starts with a very helpful literature review of the “elephant in the exam room,” as I call it, the fact that patients don’t remember most of what doctors tell them during visits. When they are tested afterward, they typically don’t remember things correctly (correct treatment was relayed back by patients to researchers in only 49% of cases after immediately leaving the emergency room). I use this data to support the idea of a written summary of every visit that patients can use by themselves, and with their families and communities. As colleagues of mine have pointed out, the written summary is not the product, the process of preparing it is.

The study itself examines three different ways of inquiring about patient understanding, in a specific and potentially scary situation, a deep blood clot in the leg. The approaches are “Yes-No” (Which most physicians will relate to as the “hand on the door knob to leave the exam room), “Tell back-collaborative,” and “Tell back-directive.”

Here’s the content of the “Tell back-collaborative” approach:

I imagine you’re really worried about this clot. I’ve given you a lot of information. It would be helpful to me to hear your understanding about your clot and its treatment.

In testing the three approaches using standardized video clips, this approach was significantly more preferable by patients, and there’s a nice discussion of what this means.

The study brings up a lot of compelling issues for me at the same time:

1. This collaborative approach could easily be worked into the after visit summary process: “I’ve given you a lot of information. Let’s compose the summary of what we talked about, together, so that your treatment is successful.”
2. In the era of secure e-mail between patients and providers, what a wonderful tool to support an approach like this and provide continuity of care. Imagine saying (in addition to the above): “I would like you to e-mail me your understanding of the condition tomorrow in the event any questions have come up, and also let me know how you’re doing.” The days of depending on the visit to ensure understanding are hopefully over.
3. As a practitioner of LEAN (Toyota Management System), this approach also speaks to the value of “getting inside” the clinical encounter, to standardize things that should be standardized (but not things that shouldn’t be standardized, like personal preferences). In health care systems, we have been anxious about scripting parts of the physician visit. I think we should move past that and use approaches that work, for every patient, every time. If every patient in a care system could expect the same approach to confirming understanding, it could change interaction during the visit, to something like, “I know she/he is going to ask me my understanding of things, so I should ask questions now, or note which areas need more explaining.”

The study does not measure whether patients were able to understand the treatment regimen from the various approaches, just which they preferred. It’s possible that their preference for an approach at the very least would have an impact on their satisfaction on the visit, and in turn on the satisfaction of the provider in helping patients understand (the “happy providers come from happy patients, not the other way around” hypothesis). At the most, a return visit, or a devastating complication could be prevented.

Our profession has incredible and incredibly complex therapies at our disposal - this is about making sure they actually help the people that we ask to use them to achieve their life goals through optimal health.

To the patients out there (all of us) - what approaches have you seen used at the end of the visit? To the providers out there - what are you willing to try during your next patient visit?

Off the Record — Avoiding the Pitfalls of Going Electronic. 2008. [Accessed April 18, 2008].

Many of the readers of this blog have probably seen these articles in the New England Journal of Medicine this week:

1. Off the Record — Avoiding the Pitfalls of Going Electronic. 2008. [Accessed April 18, 2008].

2. Personally Controlled Online Health Data — The Next Big Thing in Medical Care? 2008. [Accessed April 18, 2008].

3. Tectonic Shifts in the Health Information Economy. 2008.

I was most interested in the Hartzband and Groopman article, which was concerned with “what does this mean for us?” The “us” referred to, though, is “us doctors.” What about “us, the people with a primary professional mission to serve the public.” (I still have this link on my mind, forwarded by Bob Moore from Group Health Cooperative). It’s possible that if patients had the same access to their electronic medical record that we do, that many of the problems expressed in the article would, as I like to say, be “self-healing.” If I know that the patient I am serving is going to read what I write, how will that impact my interest in making it accurate? (My guess: A lot)

See what you think, comments welcome of course.