The Doctor Weighs In

Brian Klepper

Today I’m in San Francisco for the Health 2.0 conference, billed as “User-Generated Health Care.” Organized by my pal Matthew Holt and his partner, Indu Subaiya, "Health 2.0" references "Web 2.0," social networking, applied to health care. 

The meeting will feature top executives from high and low profile IT firms that either are already dedicated to or hope to play an important role in health care, like Google, Microsoft, Yahoo, Intel, Cisco, WebMD, Revolution Health, AthenaHealth, Sermo, and many other lesser known organizations, all discussing their strategies for leveraging data in new ways to create value for all health care constituencies.

Elsewhere, I’ve referred to this as a “significant portion of market-based health care reform, with NONE of the usual suspects." What I mean by this is that, by and large, the players working in this space are NOT the people we've typically seen at important health care conferences in the past, and they may be pooh-poohed by many longstanding health care power players. That could prove an error in judgment. 

At one level, many Health 2.0 sites are about patients creating content for other patients based on their own experiences, and by doing so contributing to a larger body of knowledge about what’s important when dealing with a particular condition.

But at another level, Health 2.0 is, in a very real sense, about corporations creating information that moves the locus of power in health care away from health care corporations and to the patient. Or for that matter, to anyone who now acts as a health care decision-maker: patient, clinician, purchaser, vendor. And in that sense, this is a revolutionary development.

We'll have a lot more to report after the session, of course. But here's s guess at some of the more exciting aspects of what we might hear.

 Imagine that a large corporation could gain access to a steady flow of clinical encounter or claims data for a sizable portion of the care delivered in the US. (Claims data is more likely at this point, but clinical encounter data has more robust clinical information and has more integrity.)  Let's say it could also get hold of lab data, image data and drug data. And let's say that company could assemble the disparate data elements into meaningful individual patient records accessible by any patient who wishes to see this information. This isn't so far fetched. Organizations like Blue Cross and Blue Shield of Florida and Humana have already created similar approaches through their payer-based patient record system, Availity.

Patient records might actually be created in two levels: one for patients and one for clinicians. Privacy and security issues are paramount. Once the patient sets up an account to allow the sponsoring organization (like a Yahoo, Google or Microsoft) to create a record, then any time his/her record is accessed, the patient might be notified, and an audit trail would exist.

If the sponsoring corporation has access to continuous rivers of data, it could analyze that information, cutting it in different ways to identify

• Patients who might be prone to have serious conditions in the near future,
• Patients who have conditions that aren't receiving the proper care,
• Physicians who provide excellent quality care or maybe not such great care,
• Drugs and devices within class that perform better or worse than others in their class,
• New best practice guidelines reflecting care approaches that consistently produce better results at lower costs, and
• So on.

The company could make this information available to all users, creating both pricing/performance transparency and accountability, but also creating information that helps patients, clinicians, purchasers and vendors make better decisions.

In the long term, new, better information might help all these players make decisions that are based more than ever on data rather than speculation. But in the short term, it would almost certainly help rationalize the tremendous excess that is now destabilizing American health care, driving down cost and helping to re-establish stability and sustainability to the system.

These are just a couple issues that will be top of mind at today's meeting. I'm sure there will be more.

The innovations we'll hear about may not be here today, but they'll be realities tomorrow or the day after tomorrow. They'll portend tremendous improvements in health care, improving quality and driving down cost, not just for health care professionals, but, more importantly,  for patients.   Health care, an industry rife with excess that derives from misaligned incentives and a lack of transparency, is filled with low hanging fruit. The new tools offered by IT are just now becoming sophisticated enough to bring tremendous value while revolutionizing the way health care works. And that's why theirpromise is so compelling.

Stay tuned.

Brian Klepper is a health care analyst based in Atlantic Beach, FL.

by Pat Salber, MD

In the early days of the clinical practice guidelines movement, doctors used to complain that it was “cookbook medicine.” As a pretty good cook, who still uses cookbooks, I say, great – when you follow the directions of experts, instead of “winging it,” you increase the odds of getting a good outcome.

So it should be not a surprise that a new study, in the July 23 issue of Archives of Internal Medicine, found that outcomes of hospitalized heart-failure patients are improved when hospital personnel follow clinical guidelines.

OPTIMIZE-HF (“Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure”) is a heart failure guidelines/quality improvement program adopted by the American Heart Association (and sponsored by drug maker GlaxoSmithKline). The program provides hospitals with tools to help improve the reliability of care, including standardized admission orders, discharge checklists, pocket cards, medical chart stickers, best-practice algorithms and critical pathways. It is currently being used by 259 hospitals across the US.

The study, led by Gregg Fonarow, MD from UCLA’s Department of Medicine, looked at data entered into an online OPTIMIZE-HF performance improvement registry. Admission, hospital, discharge care, and outcomes (death and hospital readmission rates) data on 48,612 heart failure patients were entered into the registry between March 2003 and December 2004. A subgroup of 5,791 patients were followed for an additional 60-90 days after they were discharged from the hospital.

The researchers found statistically significant improvements in three of four of the Joint Commission on Accreditation of Healthcare Organization's performance measures used to gauge the quality of heart failure care in hospitals. They included:

· Better patient discharge instructions. The rate of giving complete medical instructions to patients increased from 46.8 percent at the beginning of the study to 66.5 percent by the study's end.

· Smoking cessation counseling. Hospitals provided smoking cessation counseling to 75.6 percent of the patients at the end of the study, compared with 48.2 percent in the beginning.

· Left ventricular function assessment. Evaluating the heart's left ventricle systolic function rose from 89.3 percent to 92.1 percent.

A fourth measure, the rate of angiotensin-converting enzyme inhibitors (ACEIs) prescribed to eligible patients at discharge was 75.8% at baseline. This rate did not improve during the 2-year study.

There was a statistically significant reduction in the mean length of stay for these patients, going from 7.5 days at baseline to 6.2 days at the end of the study. In addition, were trends for reduction of in-hospital mortality, postdischarge death, and combined postdischarge death and rehospitalization, but they did not reach statistical significance.

So patients did better and hospital days were reduced (and so were costs presumably). What’s not to like? According to the lead author, Dr. Fonarow, as quoted in the Washington Post:

"If similar improvements had occurred at hospitals nationwide, this would translate to 40,000 less deaths and 1.4 million costly hospital days eliminated per year. Despite compelling scientific evidence and national guidelines for use of key life-prolonging agents and lifestyle changes, gaps exist in heart failure treatment. We hope more hospitals will adopt this validated model for enhancing heart-failure patient care."

Amen.