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.


Read the rest of this entry »

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.

This book, touted as one of the best business books of 2006 by The Economist, is about challenging conventional wisdom in business to succeed, with a focus on several companies (and their leaders) who have done that successfully. I tend to be a big fan of the case study because I love a good story, so the read was a very entertaining one.

The book follows the tradition of several of the other business books out there that I’ve read that emphasize the benefit of involving customers in innovation, through user generated content, or in the discussion here, “outside innovation.” There are a few interesting companies out there whose purpose is to bring ideas in house and either partner for development or provide rewards to inventors.

I especially liked the focus on human resources, and the discussion of “stars” versus “systems” in human resources. It’s not an either or, the authors conclude, neither “successful mediocrity” nor the fight for the best talent is a recipe for success:

Organizations that are content to fill their ranks with unremarkable performers aren’t likely to achieve remarkable performance.

They argue that companies should invest in stars and systems. I like the term from IBM, “humbition,” which is a “…subtle blend of humility and ambition.”

One thing the book doesn’t lay out well is the mystery of the “how?” these mavericks become what they do, and I think that rolls up to the read-between-the-lines in several of these books regarding the role of charisma and whether leaders are born or made. I like the idea that you can’t make a star, but systems and stars need each other. Some people have it within them, and I think that’s what distinguishes the leaders in this book. I liked Jack and Suzy Welch’s description:

Good leaders manage and good managers lead. So where’s the dividing line? We’d wager it only comes into play when you don’t want to offend an employee who crosses t’s and dots i’s but couldn’t excite a busload of kids bound for Disney World. In such a case, what do you say? You got it. “You’re a good manager.”

Grumbach K, Mendoza R. Disparities In Human Resources: Addressing The Lack Of Diversity In The Health Professions. Health Aff. 2008;27(2):413-422. [Accessed March 27, 2008].

This is a nice analysis of solutions from the Family and Community Medicine Team at University of California, San Francisco, to support diversity in the health professions, which unfortunately have not yet reached levels comparable to the general population, especially in allopathic medicine.

There are two concepts that reinforce that this is not just an issue for health care, it is an issue for society, and the people and businesses that depend on a strong health care system:

The business case highlights the customer service and competitive advantages to the health industry of having a workforce that is culturally and linguistically attuned to the increasing diversity of the nation’s health care consumers.

and

A wide group of organizations—including the AAMC and other health professions educational organizations, higher education institutions, consumer groups, and Fortune 500 companies—contributed amicus briefs and other documents in support of the University of Michigan in Grutter v. Bolinger, signifying a more concerted effort to identify and organize stakeholders interested in supporting diversity efforts.

Many physicians, myself included, work in the most downstream parts of this ecosystem, and it’s therefore helpful to consider that there are places we can be to create a more effective care system for everyone. From my travels to date, it’s clear to me that these are worthy investments of my physician colleagues’ expertise. None of us enjoy waking up to a world where the quality of health care is dependent on things other than the fact that you are a human being.

Bodenheimer T, Berenson RA, Rudolf P. The Primary Care-Specialty Income Gap: Why It Matters. Ann Intern Med. 2007;146(4):301-306.[Accessed March 27, 2008].

Sepulveda M, Bodenheimer T, Grundy P. Primary Care: Can It Solve Employers’ Health Care Dilemma? Health Aff. 2008;27(1):151-158. [Accessed March 27, 2008].

Where I am living and working, primary care is receiving a lot more attention - more than I have ever experienced it getting. That could be because I have been living and working in a place (Seattle) where primary care and family practice is well understood and now I am in a place where maybe it is not understood as well (Washington, DC), or there could be a change in conversation happening nationally. I think it’s a little of both.

I recently read the attached articles - there are many more from these distinguished authors, and for every article, many many blog posts covering the topic of primary care survival.

The articles, for me, highlight the idea that from a societal perspective, primary care helps people achieve their life goals through optimal health. The societal part means that this is good for people, their families, their employers and their communities. Paul Grundy, MD, in particular is raising awareness of the role of employers in supporting a balanced care system.

The articles also highlight that not everyone is taking a societal perspective in the discussion. From the Bodenheimer article:

It’s unclear whether the medical profession - with different specialties having distinct monetary interests and different estimations of the professional value of their work - can agree on substantial changes in payment policy on its own

This strikes me as a wise statement to make based on current conditions. At the same time, in the work I have done to help transform a health care system using LEAN (Toyota Management System), I have learned that this condition can change, and physicians can come together, if the view we take is one about the patient (which is really one about society).

When I walk into a room in my health informatics role, I feel that I am representing myself as a physician, rather than as a family physician. This helps me be aware of the contributions my specialty colleagues make to improving primary care and the skills of the people who deliver it. Their contributions are significant. Because of this experience and my experience practicing the Toyota Management System, I have an interest in the inclusion of all physicians (and all patients) in this discussion. I am wary of writing that implicitly or explictly states that the tension should be or is between primary care and specialty care. I think our patients and our society are wary of that idea, too.

I’ll end my comments there and welcome others’ ideas.

The Big Switch: Rewiring the World, from Edison to Google

This book was recommended to me by another Health Information Technology professional, and I really got a lot out of … the first half of it. I was so on the fence about what I thought about it as a whole that I looked up both the review of the book on BusinessWeek.com, and I read Nicholas Carr’s article “IT Doesn’t Matter,” from the Harvard Business Review to check on my thinking.

I’ll start with the first half, which was very engaging and engrossing, comparing the rise of the electrical industry to the commoditization of information technology. I have read about the electrical industry before, but not so well laid out. There are many parallels worthy of drawing, such as the way our culture was deliberately and unintentionally changed as a result of electrification. Fascinating, especially around the way that managing a household changed - the same number of hours doing house work, just higher expectations and more technical skill required. This is where the HBR article also helped a little bit, because the concepts are important for health information technology. In the article, he says

In the earliest phases of its buildout, however, an infrastructural technology can take the form of a proprietary technology. As long as access to the technology is restricted - through physical limitations, intellectual property rights, high costs, or a lack of standards - a company can use it to gain advantages over rivals.

That sort of sums up the state of Health Information Technology, and a nice analysis done of this recently also alluded to the idea that there’s an inertia present among vendors that’s keeping HIT in this phase.

That’s unfortunate.

That HIT though. What about the rest of IT within a health care company - the storage servers, the document creators, e-mail, etc. He says

In the long run, the IT department is unlikely to survive, at least not in its familiar form. It will have little left to do once the bulk of business computing shifts out of private data centers and into “the cloud.”

The HBR article helps here as well, where he says that the IT buildout in most companies is complete, and “Commodities can be essential to business without being essential to strategy.”

The second half of the book is about the “World Wide Computer” and the implications that it has for privacy and the general threatening of industries as we know them today. I think the data about the publishing industry is compelling and of note - 13 percent, or 150,000 jobs lost since 2001. This potentially awaits any industry that is disintermediated.

I thought, though, that this section was written for a different generation of reader, though, one who has not grown up with computers. It’s a nice overview and a lot of the truths make sense, but they didn’t seem like revelations to me in my GenX state. I was really hoping for more detail on how the new IT department would be like and how companies were moving to things like employee asset management and software as a service.

So, maybe worthy of a read, at least the first half, from your local library or book rental service (more on this in a future post).

There are some provocative ideas and I would be interested in learning about companies that are moving to software as services across the enterprise, so reduce the waste of excess storage and maintenance of data centers. If anyone knows of companies doing this, let me know either in the comments or by contacting me directly.

Osborn RF. GE and UNIVAC: Harnessing the High-Speed Computer. Harvard Business Review. 1954;32(4):99-107. [Accessed March 15, 2008]. If you do not have access to a database that hosts this article, you can look at this one.

I feel so unoriginal, and yet enlightened at the same time.

In my ongoing interest to understand where we came from, so we can move ahead, I was alerted to this article while reading The Big Switch: Rewiring the World, from Edison to Google (review coming soon), and had to read it. It has enough quotable quotes to fill 10-20 different presentations on health information technology, because a lot of what we’ve done has happened before. Just begin with the opening:

How soon the first complete electronic accounting system can be seen depends not on the business machine companies, and not on the engineers, but on the controllers themselves.

The article was written by the Manager of the Business Procedures Section at General Electric’s Louiseville plant, describing how General Electric would decide to spend almost $1 million on a tool that had never been deployed in business - the computer.

In the discussion, the fears and promise of an entire information technology industry are presented. Everything from the maverick nature of IT professionals (businesses not embracing this technology were referred to as “Rip Van Winkle”-esque, asleep to the future), to the desire to integrate the tool into ongoing operations:

…we should avoid both the deadening effect of all the limitations that are so often attributed to electronic computers and the frightening requirement of “rethinking entire operations” according to the prescription of so many of the experts of the subject.

That’s a challenging notion - we talk today about rethinking health care processes in anticipation of health information technology implementation. How successful are we at doing that? This paper gives clues that we came from a place where the bias was not to rethink things.

There are other fears presented, each managed by the GE team, including that an entire “electronic brain” would take over the decision making of executives. The computer was deliberately not put in a position to do more than provide information and speed repetitive tasks.

There is also the beginning of the personalization of the computer. UNIVAC is referred to as a person, even a baby, when the author says that it will be tended to and “nursed” by the data centers that will support it. I think we still live with that notion today, that a computer is a person, which generates various emotions among its users.

The article provides a lot of thinking for what the hopes were and whether they were met. In some ways, business went too far, by automating too much. LEAN students like myself are working to dismantle automation in many cases - more databases does not yield more understanding we have now found. The article also failed to predict the impact of the information technology infrastructure that would have to be developed to support this utopia - up to 45 % of capital costs of some companies in the last decade.

One thing that resonated with me (of course) was the emphasis on optimism in the leaders that would enter this new industry. For the leadership of their new computer group, they sought someone with

…enthusiasm, vision, foresight, energy, and an optimistic point of view; he [sic] should be willing to take risks and to devote his entire energies and thoughts to the task at hand.

Is Health Information Technology 2008 equal to General Electric 1954? A little. At the same time, it’s nice to hear that optimism has not gone out of style. It’s always worth looking at our past in the interest of saving some time for the future.

Concidentally, I ran across this post on fellow physician Jay Parkinson, MD’s blog, which also harkens back to a future once dreamed of.

[Note: The article is copyrighted and as far as I can tell, not available for purchase on the Harvard Business Review web site. I have linked instead to another article about the GE UNIVAC purchase]