…research published Monday in the Journal Health Affairs found that doctors using computers to track tests, like X-rays and magnetic resonance imaging, ordered far more tests than doctors relying on paper records.

The use of costly image-taking tests has increased sharply in recent years. Many experts contend that electronic health records will help reduce unnecessary and duplicative tests by giving doctors more comprehensive and up-to-date information when making diagnoses.

The study showed, however, that doctors with computerized access to a patient’s previous image results ordered tests on 18 percent of the visits, while those without the tracking technology ordered tests on 12.9 percent of visits. That is a 40 percent higher rate of image testing by doctors using electronic technology instead of paper records.”

I can’t say that I’m surprised by this. I remember something similar when I was working as the night pharmacist at Salinas Valley Memorial Hospital in Salinas, California. Physicians that were using pre-printed order forms to admit patients – now considered the standard of practice – almost always wrote for more PRN medications than those that didn’t use pre-printed order forms. We used to call them “don’t call me orders” because they covered every possible what-if for the patient, i.e. what if they have pain, what if they get a fever, what if they get indigestion or constipation, and so on. And why did they do that? Because it was easy to check a box, that’s why.

I think highly of Shareable Ink. I like the concept and think it provides a nice bridge between where we are today and where we need to be. I first mentioned Shareable Ink back in November 2009. It was a good idea then, and it’s a good idea now.

Abstract

Background: People with cystic fibrosis have a high treatment burden. While uncertainty remains about individual patient level of adherence to medication, treatment regimens are difficult to tailor, and interventions are difficult to evaluate. Self- and clinician-reported measures are routinely used despite criticism that they overestimate adherence. This study assessed agreement between rates of adherence to prescribed nebulizer treatments when measured by self-report, clinician report, and electronic monitoring suitable for long-term use.

Methods: Seventy-eight adults with cystic fibrosis were questioned about their adherence to prescribed nebulizer treatments over the previous 3 months. Self-report was compared with clinician report and stored adherence data downloaded from the I-Neb [2] nebulizer system. Adherence measures were expressed as a percentage of the prescribed regimen, bias was estimated by the paired difference in mean (95% CI) patient and clinician reported and actual adherence. Agreement between adherence measures was calculated using intraclass correlation coefficients (95% CI), and disagreements for individuals were displayed using Bland-Altman plots.

Results: Patient-identified prescriptions matched the medical record prescription. Median self-reported adherence was 80% (interquartile range, 60%-95%), whereas median adherence measured by nebulizer download was 36% (interquartile range, 5%-84.5%). Nine participants overmedicated and underreported adherence. Median clinician report ranged from 50% to 60%, depending on profession. Extensive discrepancies between self-report and clinician report compared with nebulizer download were identified for individuals.

Conclusions: Self- and clinician-reporting of adherence does not provide accurate measurement of adherence when compared with electronic monitoring. Using inaccurate measures has implications for treatment burden, clinician prescribing practices, cost, and accuracy of trial data.

1. CHEST August 2011 vol. 140 no. 2 425-432
2. Detailed information on the I-neb AAD System.

More and more studies are questioning the efficacy of electronic health records, and the U.S. Food and Drug Administration has begun collecting reports involving electronic health and IT errors, some of which have resulted in death…

“The thing about these systems is that it doesn’t really look like they’re getting any cheaper,” he said. “And the upgrades and the upkeep represents a very significant cost, especially in outpatient clinics.”

Of those, 163 contained mistakes that could have led to “adverse drug events.” Most errors were mistakes of omission — a doctor left out an important piece of data.

Notably, this “is consistent with the literature on manual handwritten prescription error rates,” the report said. But the larger point is computerized systems do not automatically outperform paper ones. [referring to: Errors associated with outpatient computerized prescribing systems. JAMIA, 2011; DOI: 10.1136/amiajnl-2011-000205]

For an industry that relies on data and evidence-based measurements to make decisions on the clinical and pharmaceutical side, there isn’t a lot of evidence supporting the notion that electronic health records produce cheaper care or better outcomes.

I think the article outlines some of the significant problems that need to be addressed before a truly effective EHR system can be utilized. We’re forcing the healthcare industry to implement a technology that they’re simply not ready for. The IT infrastructure in healthcare is built on marbles and is still years behind the consumer market in all but the most advanced facilities. In addition we continue to struggle to standardize information. We first need to understand what the information will look like before we begin forcing everyone to use it.

There’s no question in my mind that sharing information across the healthcare continuum is paramount to providing safe, efficient, cost effective healthcare. However, there are some key pieces of the puzzle missing. Without those pieces we’re not going to get the whole picture, and that’s a problem.

• 80% were concerned with stolen personal information
• 64% were concerned with lost, damaged or corrupted files
• 62% were concerned with the misuse of information”

I’m not surprised by the numbers. In general people are afraid of change and the unknown. With that said, I think all you need to do is walk a patient through the paper processes that we use now to give them some insight into how bad things really are. Stolen and lost personal and medical information is a major problem within the current healthcare system. It’s not uncommon in any given week to hear about patient records that have been lost or stolen. And as far as misuse of information, well lets just say that’s all too common as well.

The advantages to an EHR outweigh the concerns listed above. Just sayin’.

The video below talks about the integration of smart pumps with Cerner at WellSpan Health in New Jersey. Interesting stuff.

I think this background is why I found the Shareable Ink approach to documentation so fascinating. I really see it as an interesting way to try and capture the benefits of granular data elements and electronic capture of the data while still enjoying the benefits of paper.

My simplified explanation of the Shareable Ink technology is as follows. You print out a form that you want to use for the patient visit. Each page that’s printed out has a unique background (although it just looks like a colored page to the naked eye). When you use the Shareable Ink pen to write on the printed out page, the pen uses a camera to record what you wrote on that page and where you wrote it. Then, once you sync the pen it recreates the document you wrote on in the system.”

I featured Shareable Ink as my Cool Technology for Pharmacy back in November 2009. I always thought a product like this would find a home among pharmacists. It offers the familiarity of pen and paper while giving pharmacists the opportunity to contribute to the electronic record at the same time. Pharmacy practice is rooted in a tradition of using paper to record information. Paper is terribly unreliable when it comes to searching for information or collecting data. I can’t tell you the number of times I’ve gone to a stack of patient “kinetics cards” to look for a piece of information only to find that the card was missing or simply misfiled. And because pharmacists are slow to adopt new technology it makes sense that something like Shareable Ink might offer a nice transitional technology as we move closer to a complete electronic health record.

EHR Bloggers: “We’re excited to bring you a major new feature for your EHR account today: drug-drug and drug-allergy interaction alerts. It’s a frequently requested enhancement and also a big step towards Meaningful Use. And, like all our features, this clinical decision support system (CDSS) is entirely free.

Drug Interaction Alerts
You will now be automatically alerted when a drug you are adding, prescribing or refilling interacts with another drug or with an allergy listed in the patient’s chart. The following video shows you how to set permissions, heed alerts and override alerts. “

To gain access and begin using the Practice Fusion EHR simply sign up for a free account here. I would encourage any practitioner that needs a robust, easy to use EHR system to give Practice Fusion a look. It’s a solid application.

I was going to try the new feature for myself, but forgot my credentials; how embarrassing.

Integration of medical device data into EMRs is highly desireable, and many vendors have broached the subject. The reality, however, is that few vendors have been able to create a reliable way of pulling that data into an usable EMR format in real-time. During this years Siemens Innovations conference, I received a private showing of Siemens EMR, i.e. Soarian, and its ability to pull data from several medical devices. As impressive as the display was it still required quite a bit of manual manipulation by the end user to be useful.

The sticking point in all this data collection appears to be the inability of all the different vendors to get on the same page. I spent some time last year speaking with one particular vendor about the issue and they agreed that the difficulty wasn’t necessarily the data, but gaining access to it.

From a pharmacists perspective data from vital sign monitors, ventilators, infusion pumps and blood glucose monitors would be of particular interest as this information is often collected manually and used to make decisions regarding patient care and medication use.

Instead of creating another third party solution to collect and manage all this information, maybe it’s time for vendors to sit down and find a common ground on which to build. I’m just sayin’.

The new Intelligent Medical Devices HIMSS Analytics white  paper referred to in the EMR Daily News article can be found here.

• Saw 3D was #1 at the box office last weekend. It’s not my kind of movie so I won’t be seeing it. My wife and I saw Due Date instead. It was good and definitely worth a laugh.
• Check out the Mirador Biomedical Compass Vascular Access pressure measurement device at medGadget. “Making sure that you are not in a carotid (or subclavian or femoral arteries, etc) is not always as simple as many think.” – Yikes! I didn’t need to know that.
• MedShare for the BlackBerry is now available in Quebec. “MedShare’s BlackBerry solution allows home care workers to access their client list, client health information and schedule on the popular BlackBerry device.” Cool. I will be getting my first BlackBerry device in a couple of weeks (new job) and I’ve been scouring the internet to see what’s out there for the device. The idea of having a BlackBerry smartphone is making the new BlackBerry Playbook look better and better every day.
• Well, it looks like IT jobs will be safe for a while longer. According to a survey by the College of Healthcare Information Management Executives “more than 60% of hospital IT executives believe tech staffing shortages, which some estimate to be a shortfall of 50,000 qualified IT professionals, will definitely or possibly affect their chances to achieve meaningful use.” And we all know what meaningful use means to hospitals; money. Now might be a good time to start thinking about outsourcing your IT department.
• There’s a great article at Healthcare IT News titled “Six best practices for EHR implementation”.  Even though the list is aimed at EHR implementation, the recommendations can be applied to nearly any healthcare technology project. Actually, you could apply to principles to nearly any type of project. The best practices include:
  • Tailor your EHR to fit within staff workflows.
  • Identify ways the EHR could potentially fail in order to prevent problems in the future
  • Don’t rush implementation, take time to train
  • In EHR implementation, practices are not extensions of the hospital
  • Eliminate duplication
  • Work with experts who have EHR implementation experience
• Speaking of EHRs, did you know that statistics show the United States is one of the slowest countries in the race to adopt electronic health records? This according to the EHR Bloggers website. In addition the site goes on to say “while the US tends to rise above other countries in other business sectors, we are severely lagging in health IT.” As odd as this may sound I’m not surprised by that statement. The coolest gadgets in the world land in the US last or are severely crippled secondary to some regulatory issue when they get here. It only makes sense that this trickles into health IT.
• If you’re looking for a unique gift idea look no further than fake product boxes. These things are funny, and what’s even funnier is that I thought the iArm Forearm Mount was a real product. It’s exactly what I would expect from an Apple Fanboy. Ha!
• Remember Dell’s Inspiron Duo? I certainly do. Sure it’s just another tablet, but the screen flips over when converted to slate mode from convertible mode. It’s just plain cool. I’ve been critical of Dell in the past, but they’ve really ramped up their game lately. Dare I say they’ve been innovative? No, let’s not get carried away just yet.

• Want the yin and the yang on whether you should buy a new tablet for Christmas? If so, then have a look at GottaBeMobile.
  • Why You Might Want To Buy a Tablet/Slate This Christmas
  • Why You Might Not Want To Buy a Tablet/Slate This Christmas
• The Motorola Defy was released this week. This little Android based smartphone sports a 3.7-inch display with Gorilla Glass, and is both water and dust resistant. Gotta’ love it.
• A recent article in The Annals of Pharacotherapy compared the “severity ranking of proprietary databases to clinician assessment” for drug-drug interactions, i.e. man versus machine. The clinicians didn’t necessarily agree with the software. Interesting. All this says is what I already knew; technology and common sense go hand in hand. Software can’t really replace a pharmacist with good deductive reasoning and lots of experience, but it can make his job easier. (Ann Pharmacother ;44:1718-1724 )
• There’s a decent article at KevinMD.com on direct-to-consumer advertising (DTC). According to the article “the pressure to prescribe an advertised medication that a patient asks for by name can be great. Physicians may feel compelled to comply with the patient’s wishes.” On the surface this can seem like a bad thing, but on occasion it could benefit the patient. For this reason I remain on the fence regarding DTC advertising. For the most part I’m opposed to it, but on the other hand it is one way to disseminate information.
• The US Food and Drug Administration (FDA) has issued another recall for Symbiq One- and Two-Channel pumps. This is the third recall for these pumps. Oops!
• Do you ever get the feeling that Apple uses a lot of smoke and mirrors to get people to buy into their singular view of the world? It appears that putting Flash on the new 11-inch MacBook Air kills about a third of the batter life. Bummer.
• Google instant is now available for mobile devices. I love the instant search feature in Google, and it’s simply awesome on a mobile device.

• The NFL Network has been doing The Top 100 Greatest Players of all time. Well, they finally made it to #1 and it’s Jerry Rice. No disrespect to Mr. Rice, but are the people at the NFL crazy? Look at the people that they put Rice in front of: Lawrence Taylor, the man that single handedly changed the way offensive lines play, particularly the left tackle position; Walter Payton. Enough said; Dick Butkus, are you kidding me? This guy defined NFL toughness at the linebacker position; Jim Thorpe at #37. Do you know what this guy did? The credibility of the list is suspect to say the least.
• It’s week 9 in the NFL people, and there are some great games on tap. Who would have thought Tampa Bay would be playing a meaningful game against a divisional opponent in November? Not me. Miami and Baltimore is going to be a slobber-knocker, as will the Pittsburgh – Cincinnati game on Monday night. Oh, so much football to watch. I can’t wait.
• Oh yeah, San Francisco won the World Series. Here’s something of interest. On Sunday night, NBC’s Steelers-Saints game drew an 11.8 national rating, while Fox’s Giants-Rangers Game 4 drew a 10.4 rating. And on Monday night Fox’s Giants-Rangers Game 5 earned a 10.6 national rating, while ESPN’s Texans-Colts game drew an 8.6. So a couple of mid-season NFL games nearly trumped the World Series. That’s worth noting. There was a time when the NFL wouldn’t dare televise a game at the same time as the World Series, but now they couldn’t care less. Baseball is a boring, slow moving sport with little of interest, while football is an action packed dynamo still building steam. Take the hint Bud and cut the baseball season back before it’s too late. I’m just sayin’.

Have a great weekend everyone.