Thursday, November 11, 2010

Radiology Examinations - How Much is Too Much

As is often the cases conflicting information in the media on the benefits of screen, x-rays and healthcare.
This piece in the NY Times: CT Scans Cut Lung Cancer Deaths, Study Finds suggests that annual CT Scans of current and former smokers reduces the risk of death form lung cancer:
Annual CT scans of current and former heavy smokers reduced their risk of death from lung cancer by 20 percent, a huge government-financed study has found. Even more surprising, the scans seem to reduce the risks of death from other causes as well, suggesting that the scans could be catching other illnesses.
And while there does seem to be some benefit as Dr Patz (professor of radiology at Duke who helped devise the study) put it:
he was far from convinced that a thorough analysis would show that widespread CT screening would prove beneficial in preventing most lung cancer deaths. Dr. Patz said that the biology of lung cancer has long suggested that the size of cancerous lung tumors tells little about the stage of the disease. “If we look at this study carefully, we may suggest that there is some benefit in high-risk individuals, but I’m not there yet,” Dr. Patz said.
And before you run out the door to get your CT scan its worth taking note of Dr Ben Goldacre's insightful blog Bad Science that takes a hard look at the science behind claims and does a great job debunking the myths and taking a hard look at statistics. But as we have seen over the last few months there is an increasing focus on excessive use of imaging technologies. Earlier this year the Imaging e-Ordering Coalition (Co Chaired by our very own Scott Cowsill) Successfully made a case to congress to include computer-based physician order entry (CPOE) solutions as a potential method for imaging utilization management in recently passed health care legislation:
the Coalition is making several recommendations to policy makers in Congress and CMS...One of the recommendations is that imaging CPOE tools should be based on consensus medical guidelines and literature, such as the ACR's appropriateness criteria. Another recommendation is that CPOE and decision support tools should be compatible with any CMS-approved electronic medical record (EMR) systems and be able to track results.
In recent news the Healthcare alliance aims to improve the imaging process, Changing the Game the coalition continues to push for
E-Ordering, also referred to as clinical decision support (CDS) (to) provide(s) physicians with real-time, electronic access to pre-exam, case-by-case decisions linked to evidence-based clinical guidelines and tailored to a patient’s specific circumstances
and cites a 7-year study at MGH (pub 2009) that showed a dramatic decrease in the growth rates of several imaging exams
  • CT exams down from 12% growth to 1%
  • MR exams down from 12% dropped to 7%
  • Ultrasound down from 9% to 4%
So with that in mind the concurrent news that Minnesota’s Institute for Clinical Systems Improvement (ICSI) is spearheading the First Statewide Effort to Help Ensure Patients Receive Appropriate High-Tech Diagnostic Imaging Tests that is targeted to save Minnesota healthcare community more than $28 million annually (this was the savings estimated from the year long pilot with 2,300 physicians from five Minnesota medical groups, five health plans taking part. You can read more about it here, and here in the Star Tribune in Minneapolis St Paul and here on ZDNet

The process and challenges are outlined in this video:

Showing how you can help the busy clinician by providing them with a simple, intelligent and above all standardized appropriateness criteria to guide the clinician in ordering the most appropriate study for the patient at the time of consultation. This improved patient satisfaction, clinic efficiencies and reduced administrative costs. While there will be those who distrust technology over seeing clinical decision making the solution does not force or prevent clinicians from ordering the test they deem the most appropriate. What it does do is provide evidence based guidance on the suitability or clinical appropriateness of the test.

How do you feel as a patient or as a clinician on technology guiding care choices? Like it or not expect to see more as we continue to cope with a veritable Tsunami of clinical data, studies and discoveries that by some estimates require a doctor to read for 70 hours per week just to keep up in their one speciality.

Friday, November 5, 2010

The Problem with Problem Lists

A colleague and friend wrote this great piece for Health Management Technology : The Problem with Problem Lists in which he reviews the history of the problem list (now over 40 years old!) and while

While their value in patient care has been demonstrated in countless studies, physicians have historically adopted them with much less enthusiasm than one would expect.

They are not as prevalent or pervasive as you might expect. IN fact this was subject to an extensive discussion on a list serv and I made the point here that managing these expanding list of problems can be a significant challenge for any system. It tends to be easy to add problems but as Davide points out 

While patients’ diseases, symptoms and risk factors evolve and change, the corresponding items on the electronic problem list tend to age rapidly and may soon become irrelevant or even inaccurate. For example, a certain symptom may have disappeared, or an initial diagnosis may have been further defined, making the initial description too generic to guide actual care. Additionally, as multiple specialists engage with a patient, they focus on problems that are both different and overlapping. While each provider contributes to the problem lists (from different perspectives), patient data rapidly becomes repetitive or redundant, rendering the electronic problem list less useful

As one of the commentators pointed out clearly defining what should be captured and documented int he problem list is a god place to start and supplementing that by cleaning up old information (archiving old details, problems and information that perhaps was relevant but has now either been over taken by events (OBE) or was relevant for a specific episode of care but is now not.

But capturing the latest information from the range of inputs remains a challenge and facilitating narrative based documentation 

to preserve detailed and expressive descriptions of patients and their stories and are commonly accepted as the best way to capture and arrange the informational background on which effective diagnostic reasoning is based.

Is preferred by many but unfortunately 

The final output of such systems is a textual clinical note.

Technology is now starting to address this problem by providing tools that analyze the content of the narrative, understanding the underlying clinical description and intent of the physician.

Consider this sentence: “The otitis media for which the patient was seen last month appears to be fully resolved.” CLU automatically and reliably assesses that the “otitis media” is “resolved” and thus should be removed from the list of current problems. Today, this action would require manual editing of the data. However, with CLU this happens automatically, with the physician confirming the deletion.

Thereby bridging the clinical divide between the physicians desire and need to document the full clinical condition in narrative form capturing all nuanced detail of the patient's history and the need to automatically extract clinical data and facilitate the integration of structured semantically interoperable data directly into the EMR.

Timely innovation given the major push towards electronic medical records as part of the governments incentives in ARRA and HITECH and relevant in any clinical setting where narrative remains the key data captured.

Posted via email from drnic's posterous