Wednesday, June 29, 2016

Guess What: Docs Don't Like EHRs

It's kind of "dog-bites-man" type news, but there is even more evidence that physicians not only don't think EHRs are helping them but actually see them as contributing to burnout.

Researchers at the Mayo Clinic found that use of EHRs (or computerized physician order entries -- CPOEs) was associated with lower satisfaction with time spent on clerical tasks, with nearly half of physicians saying the amount of time spent on clerical tasks was unreasonable.  No wonder the AMA CEO recently complained that physicians were turning into the "most expensive data entry force on the face of the planet."

Not surprisingly, 63% of physicians believed EHRs made their jobs less efficient.  Also not surprisingly, their use was  associated with a higher rate of physician burnout.  Most importantly,  physicians were split on whether EHRs improved patient care or not.

It is almost shocking that "only" 44% said they were dissatisfied with EHRs.

The burnout is a problem not just for the physicians themselves, but also for patients.  As the lead author said,
Burnout has been shown to erode quality of care, increase risk of medical errors, and lead physicians to reduce clinical work hours, suggesting that the net effect of these electronic tools on quality of care for the U.S. health care system is less clear.
That doesn't sound like a good return on our $33b HITECH investment, does it?

A separate study by researchers at Cleveland State University agreed that EHRs presented a number of "clear challenges," including increased workload for caregivers, issues around trust in the technology and the information in it, and a perceived over-reliance on technology.

The CSU study found that, in many cases, physicians simply created "workarounds" to circumvent aspects of the EHR, a finding that was echoed by a VA study looking at EHRs and test results.  The VA study found that 43% of physicians used EHR workarounds to follow-up on test results, most commonly paper-based methods like sticky notes.

The respondents complained it was hard to find test results in the EHR a second time, that the EHRs generated an overload of alerts and reminders, and that paper was necessary to track results from providers not on the same EHR.

Yet another study found that one of the most common workarounds by health care professionals had to do with cybersecurity.  They've found lots of creative ways to do so, including posting sticky notes with passwords, passwords shared by entire hospital units, and preventing automatic logouts.

The authors concluded:
"We find, in fact, that workarounds to cyber security are the norm, rather than the exception.  They not only go unpunished, they go unnoticed in most settings — and often are taught as correct practice."
No wonder hackers are having a field day with health data.

Interestingly, as much as we see physician complaints about EHRs, the CSU researchers warned of a "culture of silence" that physicians found in their organizations which keeps them from speaking up about issues with EHRs and ensuring that they are properly addressed.

Since health systems are spending millions of dollars on implementing EHRs, they may not be eager to hear physicians complain about them.  It may be easier to chalk issues up to short-term implementation snafus or to user error, rather than to structural issues with the EHRs they've chosen.

The authors of the various studies had similar recommendations, urging that future generations of EHRs needed to do a better job of integrating with clinical workflow, as if this was a novel idea.  It begs the question: how has so much money been spent on products used by so many health professionals for so long now, with such dismal results?

And despite all that spending and all those headaches, we're still failing on key goals.  There's not much confidence by anyone that EHRs are helping patient care, we're still failing at sharing patient data across providers (which Commonwealth Fund president David Blumenthal calls "the biggest obstacle to the health care revolution"), and we're not making it easier for physicians to do their job.

For example, an analysis of drug treatments on 250 million people with diabetes, hypertension, and depression found that at least one on ten patients had a unique course of drugs, one that no one else had.  That figure as as high as 25% of hypertension patients.  This is the kind of variability that electronic records make possible to detect, and that EHRS should be able to instantly warn about  - both to the prescribing physician and to the persons/organizations overseeing/regulating them.

Yet here we still are.

At the risk of grossly oversimplifying, the problem that current EHRs are really "solving" is that most health care records were still on paper.  We're fixing that problem all right, but that's not one of health care's big issues.

What we should care about is tracking and improving patients' health.  We need better data -- and more information -- in order to coordinate care, reduce duplication of services, measure outcomes, and track performance.

Having ONC certify acceptable EHRs is a classic example of stymieing innovation through government regulation.  Through lots of good intentions, we've frozen the market in a very early stage of development, and the physician dissatisfaction with EHRs is the result.  Which EHR a provider uses -- or even if they use an EHR at all -- is not the point.  The ability to provide the data we need is.

Let the market figure out the products that will delight their users while delivering that data.

Imagine what mobile phones would look like if the federal government had mandated in the beginning of the century what they had to do and how they had to do it.  We'd probably all be using versions of the classic Blackberry.  Most of us would not settle for that, and we shouldn't settle for what EHRs are doing now.

EHRs causing workarounds and physician burnout are the proverbial canaries in the coal mine, signaling we are on the wrong path with them.

Thursday, June 23, 2016

Millennials Are (Not) So Different

Millennials get a bad rap.

If we believe conventional wisdom about them, they like to live with their parents, at least until they can move into their urban-center condo.  They hate to drive.  They're maddening in the workplace, demanding lots of frills and constant praise yet returning little loyalty.  They're hyperconnected through their various digital devices.  And, when they deign to think about health care, which isn't often, they want all digital, all the time.

There's some truth to the conventional wisdom, but not as much as you'd think.  A new study from Credit Karma flatly asserts that "everything you thought you knew about Millennials may be wrong," finding that they still have aspirations to much of the same "American Dream" as previous generations.  

It is true that living at home is, for the first time in recorded history, the most common living arrangement for U.S. 18 to 34 year-olds, with almost a third doing so.  However, millennials
 overwhelmingly still hope to get married and buy a house.  In fact, they accounted for 35% of home sales in 2015, and most of those were in the suburbs.  Two thirds of millennials already describe themselves as suburban.

It's not quite true that they don't drive; after all, three-fourths of younger millennials (ages 20 to 24) have drivers licenses.  However, that compares to over 90% thirty years ago.  Millennials are also buying cars at a much lower rate than previous generations. These shifts have been attributed to more online social and entertainment options, to high car prices, and to the availability of ride services like Uber.

As for those new demands in the workplace, maybe not so much.  Bruce Pfau extensively rebutted this notion in Harvard Business Review.  He cited a review of over 20 studies which concluded that "meaningful differences among generations probably do not exist in the workplace."  Their top priorities in their workplace are making a difference in their organization and in the world -- as they are for Gen X and Baby Boomers.  Contrary to popular belief, they don't even job hop more frequently than previous generations.

The hyperconnected part is certainly true.  Millennials are much more likely to have a smartphone,  and -- jawdroppingly -- on an average day they interact with it much more than with anyone else, even their parents or significant other.  No wonder they are more likely to be anxious or bored when they don't have access to their smartphones (although they're much more willing to unplug when on vacation).

Things get really interesting when it comes to health.  Millennials are often viewed as not very interested in health care, but it is the second most important social issue for them, right after education and ahead of the economy.

deep dive on millennials and health care by the Transamerica Center for Health Studies had some results that also don't necessarily fit the stereotypes:

  • Taking care of their health was tied with getting/keeping a job as their top priority.
  • 70% have been to a doctor's office within the last year, although for minor issues they're more likely to head to urgent care/a retail clinic.
  • 72% have a primary care doctor -- but only about a third expect them to coordinate all their care.
  • When it comes to getting health information, this supremely digital generation still relies most heavily on health care professionals and friends/family (especially their mothers!).
  • Having enough time with their doctor is their most important quality-related characteristic, over other features like technology .
  • While 77% rate their health care good or excellent, that is down ten percentage points from three years ago.  Half reported having some health condition.
There has been a dramatic drop in being uninsured -- 11% versus 23% as recently as 2013 -- but millennials don't like much about health insurance.  They feel much more informed about their health and how to improve it than they do about how to find health care services or their health insurance options.  E.g., 35% felt uninformed about health insurance options, versus 8% about their health.

Perhaps that is why two-thirds have never comparison shopped for health insurance.

Lastly, TCHS found that millennials rate affordability as the most important aspect of the health care system, but many don't find it affordable.  About 20% can't afford routine health expenses, even though millennials' median health expenses are under $100 per month.  Nearly half have skipped care to reduce their expenses.

Similarly, most millennials view monthly premiums over $200 as unaffordable; a third think anything over $100/month is unaffordable.  About 30% of the uninsured don't ever plan on being insured, but affordability is the problem, not invincibility.   Affordability is especially an issue for millennials because, on average, they are making less than their parents did at the same age, while struggling with record student loans.

If there is a key difference with millennials' health care, it may be in their emphasis on technology.  A report from found that:

  • 76% of millennials valued online reviews in choosing a doctor, with 74% valuing online scheduling and bill payment;
  • 73% want doctors to use mobile devices during appointments to share information;
  • 63% are interested in providing data from wearables to their doctor;
  • 60% are interested in telehealth options in lieu of office visits.
Another recent survey found that 77% of millennials wanted to use technology to track their health, which was "at least" 10% more than older generations.  In fact, 55% of millennials with diabetes said they would trust a health app for advice over a health professional alone (although most said health apps actually helped them connect more often with their doctors).

It is perhaps no wonder millennials are turning to technology when it comes to their health.  They highly value face time with their doctor, but they may not be getting it.  According to the Salesforce report, 40% of millennials don't think their primary care doctor would recognize them on the street.

Many of us might suspect the same thing, and that should trouble us all.

When it comes to health care, as with many other aspects of life, it may be less that millennials are different in what they want as it is that they're quicker to adopt newer options for getting it.  The rest of us should learn from that, not shake our heads at it.

Wednesday, June 15, 2016

Not All Snake Oil Is Digital

The head of the AMA -- James Madara -- got a lot of headlines with his speech at the AMA annual meeting last weekend that, among other things, warned of the "digital snake oil of the early 21st century."  Dr. Madara included in this category "from ineffective electronic health records, to an explosion of direct-to-consumer digital health products, to apps of mixed quality.

Dr. Madara is frustrated with products that make care less efficient -- he cited an AMA study that found 50% of physician's time was spent on a keyboard, making them "the most expensive data entry workforce on the face of the planet" -- while interfering with the patient-physician relationship, and many of which have no proof of efficacy.  

Not surprisingly, he scorns the DIY health movement.

But, not to worry.  Dr. Madara promised that physicians will be involved in future generations of such digital products, rather than their being developed "flying on an entrepreneur's incomplete views."   He seems to believe that digital health vendors have neither consulted with physicians nor have any on their teams.  He also ignores the fact that health care providers have allowed the federal government to pay out some $33b in our tax dollars on those digital snake oil EHRs for them, rather than holding out on principle for better products.

A different take on "snake oil" in health care was a thoughtful piece in Health Affairs, by David Newman and Amanda Frost, discussing the quality measurement morass in health care.   They cite a study that estimated we spend some $15.4b annually collecting several thousand different quality measures, few of which have any meaning to consumers and all-too-few of which seem to be used to actively improve quality.

It isn't that they don't think we should be measuring quality -- far from it -- but, rather: "Patients should not be able to choose substandard quality care, and substandard quality care should not be allowed to be offered in the market."

Now, there's a novel concept!

They noted that you can't eat at restaurants that fail their health inspection, even if they were to offer lower prices to compensate for the lower quality.  They're closed until the identified issues are addressed.  Yet you can get care from providers who are known, objectively or subjectively, to be delivering substandard care.  And, oh, by the way, the people overseeing who is allowed to keep delivering care are other physicians; it is as if the restaurant association was responsible for those restaurant health inspections.

Dr. Newman and Dr. Frost want to hold providers, payors, managers, professional associations, and regulators responsible for demanding quality improvement, rather than throwing a bunch of quality metrics at consumers in hopes that they will sort it out somehow.

That's the kind of snake oil that the AMA should be targeting.

It's not just poor quality care.  It's also care of questionable -- or even no -- value.  Stat News just published an article profiling a tool that most consumers, and probably many physicians, have never heard of.  It's called "number needed to treat," or NNT.  It is a calculation that quantifies how many people would need to get a given therapy in order for one person to benefit from it.  You'd think that number would be close to one, but it rarely is.

For example, seven post-surgical patients have to wear compression stockings to save one from developing deep-vein thrombosis (blood clots).  Moreover, the downside risks of wearing them are minimal, so having them as a common practice makes sense.  On the other hand, 104 healthy people would have to take statins for five years in order to save one from a heart attack.  Almost 1,700 healthy people need to take aspirin every day for a year to prevent one heart attack or stroke.

Those are not such great odds of success.

Experts suggest that NNTs of 5 or less are associated with a meaningful health benefit, and over 15 probably at best only a small one.  The amazing thing is how many therapies have high NNTs.  The NNT website rates therapies into four categories:

  • Green: clear health benefits that outweigh any associated harms.  Example -- antibiotics for open fractures.
  • Yellow: the data are not clear about benefits/risks and require more study.  Example -- antibiotics for sinusitis.   
  • Red: Benefits and harms are about equal.  Example -- antibiotics for acute bronchitis.  
  • Black: "Very clear" associated harms without any recognizable benefit.  Example -- PSA test for prostate cancer.  

NNT also reviews diagnostic evaluations, providing a color-coded summary of how helpful they are for the particular disease conditions.  Again, there are extremely wide variations.

The question is twofold: one, why are so many of the therapies with red or even black ratings still performed, and, two, why isn't the NNT always part of the conversation with the patient?   For that matter, why isn't the NNT available for more therapies?

Yes, certainly EHRs should be better.  Yes, direct-to-consumer digital health products and apps should be thoroughly (and transparently) evaluated.  Yes, physician offices should be part of the digital data ecosystem surrounding each person, taking advantage of, and contributing to, data about that person and the broader population.  And, no, data entry is not what we want our health care providers spending the majority of their time on.

But all that is the tail wagging the dog.  In the early 21st century, we should have better data on the effectiveness and risks of what is being done to patients.  That data should be available to guide physician recommendations and patients' informed consent about their care.  Those are the discussions we deserve to be having.

If we're making decisions in the absence of such data -- or despite it -- then we're back to the "snake oil" days Dr. Madara proudly claims the AMA took care of over a hundred years ago.  This time, though, they're the ones selling it.

If we're going to be talking about "snake oil" in health care, there may be better targets than apps.

Wednesday, June 8, 2016

This Actually Is a Test

When it comes to health care, testing is not what it used to be, or what it is going to be in the not-too-distant future.

For example, confirmation of a cancer diagnosis is getting much easier.  The New York Times reported that blood tests -- known as "liquid biopsies" -- have now been shown to generally match the results of a tumor biopsy.  The blood tests look for DNA fragments from the tumor that signal its presence.  The liquid biopsies are useful for both detecting the presence of a tumor and its ongoing monitoring.

The current generation of tests are not perfect, with as many as 15% of tumors not generating enough DNA to be detected, but they do offer the advantage of not requiring an invasive procedure.  The expectation is that testing will get even better, allowing for earlier detection of more cancers, although the problems of both false positives and detection of tumors that would not end up harming the patient if left untreated remain.

The FDA has just given approval for one such test, and numerous companies are vying for position in the space -- STAT reports that some 38 companies in the US alone are working in it.  With direct-to-consumer lab tests becoming more of an option, we may soon have more cancer diagnoses, with more decisions required about what needs to be treated versus just monitored, and, indeed, what is "cancer," since some tumors grow only very slowly or not at all.

Still, if we have a choice -- and we soon will in many cases -- most of us would probably opt for a blood test rather than a biopsy.

The concept of what constitutes a "test" itself is undergoing some broadening.   Instead of an actual test, liquid or otherwise, Microsoft reported that they may be able to use your search history help determine if you have cancer, even before you or your doctor realize it.  They think their approach can be extended to other serious illnesses, helping catch them at earlier stages.

The Microsoft researchers used search logs to identify people whose queries strongly suggested they'd been diagnosed with pancreatic cancer.  Then they worked backwards on those people's search histories to determine what kind of queries were associated with the subsequent diagnosis.  There may not have been any actual diagnostic tests or procedures done yet, possibly just searches on symptoms, but they found "signals" in the search history.

The method isn't perfect, but the researchers claim: "We find that we can identify 5 to 15 percent of cases while preserving extremely low false positive rates."  They believe their false positives are on the order of 1 in 100,000, which compares very favorably to most actual diagnostic tests.

Gosh, if Bing can do that, imagine what Google could do

The researchers were quick to note that their research was only a proof of concept and that Microsoft has no plans to develop a product based on the discovery (which seems odd!).  Instead, they wanted to get the medical community "excited" about the approach in hopes that it could end up being used as an early warning system for serious diseases.

Microsoft researchers had previously used search data to help identify unreported prescription drug side effects, and there was also the Google effort to use search data to help predict flu epidemics, which ended up not quite working out as planned, although the approach is far from dead.  These examples all illustrate that artificial intelligence can use Big Data to find things out about our health that we might never have otherwise found, or found out too late.

One of these days you may be typing in a search and Cortana politely but firmly might suggest that you better see a doctor for a specific potential diagnosis.  It might even set up a Skype call with a specialist for you.

Some of the most intriguing changes to testing relate not to diagnostic tests, but to clinical trials.  Researchers at the Lawrence Livermore National Laboratory are developing a "human-on-a-chip" that they hope could predict the impact of drugs, viruses, or toxins on humans.  The chip, known as iCHIP, essentially models the workings of human biological systems -- currently the central nervous system, peripheral nervous system, the blood-brain barrier, and the heart.  Actual cells, such as neurons, are seeded on a chip, and microelectrodes can do real-time monitoring of electronic signals from them.

The hope is that use of iCHIP will lessen or even eliminate the need for animal or even human testing.  Use of animals for testing (particularly for cosmetics) has become highly controversial, even banned in some cases.  Congress is close to passing a bill that would encourage the use of alternatives to animal testing.

There are both ethical and efficacy questions with animal testing, so iCHIP may be an idea whose time has come.  Indeed, iCHIP's principal investigator boldly says: "The ultimate goal is to fully represent the human body," integrating all the biological systems together to create a "complete testing platform."

Chimpanzees everywhere may be breathing a sigh of relief.

If Microsoft is using Big Data to take the place of many standard diagnostic tests, a company called Insilico Medicine is trying to do the same with clinical trials.  They use deep learning and artificial intelligence to predict how a drug will impact human cells, rather than relying on animal trials.  

Alex Zhavoronkov, Insilico's CEO, believes that:
"...animal testing is not very representative of what the human outcome will be...We need something better, and something better is creating a virtual human to simulate the activity of many drugs on many tissues at once.  That can only be done using really deep data."  
Creating a "virtual human" or putting all the human biological systems on chips are ambitious goals, especially given our increased recognition of both the complexity and importance of our microbiome (whose cells outnumber ours).  On the other hand, no one is particularly happy with the cost and timeliness of clinical trials, animal or human, and identifying health issues sooner and less invasively is certainly desirable.

OK, so maybe we're not getting a tricoder anytime soon, but, all in all, we're making real progress on testing.

Wednesday, June 1, 2016

Fewer Moonshots, More Walks

In a provocative op-ed piece, Jarle Breivik, a professor of medicine at the University of Oslo, takes aim at the National Cancer Moonshot Initiative announced earlier this year by President Obama.  Nice try, he concedes -- but the reality is: "We’re a lot better at fighting cancer. We just can’t cure it."

Is this stereotypical Norwegian pessimism or just some badly needed Scandinavian bluntness?

Dr. Breivik points out that cancer is fundamentally a disease of aging, and none of us is getting any younger.  All our efforts to improve lifespan end up putting us at risk of living long enough that we'll get some form of cancer.  We've gotten a lot better at treating cancer, and there are new developments that promise to make even greater impacts (more on that later), but as Dr. Breivik points out: "Every time we cure a person of cancer, we produce a person with an increased probability of getting cancer again. It is the Catch-22 of oncology."

We love to use terms like "moonshot" -- even Google uses it for their most ambitious projects -- but Baby Boomers are the last generation to whom it actually carries any real meaning.  That same generation is also getting into the years when cancer becomes more of a risk, so perhaps the use of it is no coincidence.  We spent the equivalent of around $200b on the Apollo program, which certainty makes the current (supposedly) $1b cancer moonshot look like doing it on the cheap....or for the PR.

 In Dr. Breivik's analysis,
The different actors are outbidding one another for attention and funding, and for more than half a century the public has been told that the cure is just around the corner....Confronted with these forces, there is little incentive for our democratically elected leaders to question the goal of the ultimate cure.
At the very least, we owe ourselves more straight talk about what we're doing.

Because, in the midst of our "war on cancer," things seem to be getting lost in the fog of the war.  A new study found that only 5% of advanced cancer patients actually understood their prognosis.  These were people who had approximately four months to live.  Thirty-eight percent had never even discussed their prognosis with their oncologist.

The lead researcher said: "We were astonished to learn that only 5 percent of this sample had sufficient knowledge about their illness to make informed decisions about their care."  "Astonished" would be a good word to use; "appalled" might be another.

It's not clear if this is due to patients not asking, or to their doctors not telling.  It is most likely some of both.  Two oncologists illustrate their dilemma in a poignant column, How Much Do You Want to Know about Your Cancer?   They can give numbers, they can speak in generalities, they can help their patients make plans, but they can't read their patients' minds about how -- or if -- they want to hear the bad news.

And it is often bad news.  In their words, for many patients they say it boils down to: "Spoiler alert: Despite all the exciting stories about progress against cancer that you’ve heard about in the news, there is no cure for most types of cancer once they have spread to other organs."

We talk about wanting to be informed patients, about taking more responsibility for our health, about being partners with our doctors and other health care professionals, but when things get scary, as they can uniquely do when it comes to our health, maybe not so much.

Maybe all this is too pessimistic.  We are making progress, to the point when many cancer patients whose post-diagnosis survival might once have been measured in months are now living for years -- sometimes apparently cancer-free.  There is particular excitement around so-called checkpoint inhibitors that help unleash the body's own immune system to fight cancer.  

Even more promising, German researchers have just published results that they believe represent a "very positive step" towards  creating a universal vaccine against cancer -- not just curing but immunizing against cancer.  That is truly the Holy Grail of cancer research.

The biggest problem is that, to date, the cost of cancer drugs has been astronomical (pun intended).  Some of the drugs can cost over $100,000 annually, making those longer lifespans not look quite as rosy, at least for the people paying that bill (that would be us, folks, one way or another).  Indeed, recent research confirms that the U.S. is getting less bang for its cancer bucks compared to other countries.  Maybe a "vaccine" will upend all the current cost-benefit calculations -- or maybe it, too, will get caught up in the big money arms race.

Imagine what a Valeant might charge for such a vaccine.

When it is us or a loved one with cancer, it often seems like no drug is too expensive, no treatment too experimental, even if it might buy only a few more months of life -- and not necessarily months with a very high quality of life.  Many of us would be willing to spend all of our savings on such options.  The problem is, we're often willing to spend everyone else's money too, and that's just not a choice we should get to make unilaterally.

All the talk of moonshots, better survival rates, and promising new treatments sometimes can lull us into a false sense of optimism.  But, hey -- Baby Boomers may not live long enough for many of them to worry about cancer.  They'll be too busy dealing with the impacts of diabetes and obesity, making them "sicker seniors" than previous generations, as NPR reported.  Unfortunately, we can make equally dubious choices about those as well.

We know our behavior can help us be healthier.  For example, new research has associated exercise with lowering the risks for 13 cancers, adding to the array of similar research findings about the impacts of healthy behaviors.  Yet the CDC says only 6% of US adults are engaging in the five health-related behaviors that are associated with preventing chronic diseases.

No wonder that Dr. Brevik concluded that, instead of moonshots against cancer, "many more lives can be saved by doing the boring stuff, like getting people to stop smoking, eat healthfully, exercise and put on sunscreen."

"Boring stuff" just doesn't get headlines the way "moonshots" do.