John R. Zaleski, PhD, CPHIMS

I remember from my own experiences with my father after his stroke what it was like shuttling him from specialist to specialist in an effort to get him the care he needed. Although medicine and medical information technology is the field in which I earn my living, there’s always something educational about firsthand experience. I am quite familiar with the field of healthcare information technology, its foibles, its benefits and its potential impact on healthcare delivery. I ran a critical care product line for a large healthcare IT vendor and am now managing bioinformatics research for another. However, the experience one gains in actually participating and operating in and around the healthcare system in the United States is one that many of us have, many of us curse, and many of us appreciate. I’d like to direct attention to several aspects of the healthcare system that we, as Americans, may consider to be mundane. However, perhaps after reading this those so inclined might have their interests piqued and pay attention somewhat more acutely to these rather mundane items and this in and of itself may cause you to re-think how improvements in the system could benefit you and your families.
We are all familiar with visiting a physician office for the first time. You know the routine: you are handed a clipboard containing half-a-dozen pages or so in which you must disclose every torrid aspect of your life. You must hand over your insurance card so a copy can be made and you must list every medication, every tablet, every vitamin you take in quantity, type, label so that THIS physician has a clear picture of who you are and what has ailed you. Some people are more organized: they make copies of this information and merely re-copy onto the forms so that they do not have to make up their stories out of whole cloth. Others are not so organized. Regardless, this information is normally maintained by your primary care physician (PCP) and is seldom shared unless you explicitly ask for records or, perhaps, your PCP is one of the more “progressive” types using an in-house electronic medical record system. Alas, currently only a relatively small number of U.S. physicians make use of health information technology. The estimate is that 17 percent of U.S. physicians and between 8 and 10 percent of U.S. hospitals employ health information systems in the form of electronic medical records for capturing and maintaining patient medical data (David Blumenthal, 2009).
However, consider having to repeat this process for each physician you visit. This takes me back to the story of my father. My father, who passed away last August, had a stroke in 2003 at the age of 85. I’ll save the experience of the basic medical challenges for another article, but I will relate that the treatment process involved half a dozen specialists and allied health professionals. All of these individuals required similar information regarding his health and history. Each one of them required the information in a format similar to the method described above with clipboard and pen.
Let’s consider for a moment an alternate method for the requisite “data transfer” experience described above. Suppose that my father’s history, medications, allergies, treatments, etc. were all contained on a single “device,” such as something having the form factor and function of a Universal Serial Bus (USB), or memory, stick. Then, if each physician and specialty practice had the capability of reading such information from this device into an electronic record that employed common interfacing and formatting so that the information could be populated in a way that would be visible and accessible to each physician, a number of benefits would have resulted. First of all, the mere physical act of copying the same information over and over would not have been required. Secondly, the likelihood of inaccurately entering information could have been avoided. Given the fact that I was the primary source for data entry, I can attest to the fact that I am error-prone! Thirdly, having a complete and accurate list of his medications, his treatment plans, clinical notes, and orders all available would have provided to each specialist a comprehensive understanding of his history. This would have enabled each of them to communicate more effectively to determine how best to treat him without having to ask redundant questions of both him and me during the visit—more time could have actually been spent in treatment!
The capability and benefits described above are not out of our reach. The technologies exist to enable the scenarios described above. The benefit to patients is obvious, as can be discerned from even this simple telling. Improving healthcare delivery can be achieved without bringing rocket science to the practice—we can begin simply by doing what we currently do more efficiently and by bringing some good sense to the practice. We as citizens think nothing about going to a store and using a credit card to pay for goods and services. Yet, we have nothing equivalent in standard practice that allows us to treat the most precious good: our bodies. In the coming weeks I hope to expand upon this theme and raise awareness on the benefits of information technology and its benefits to healthcare.

One of the chronic ailments that my father suffered from was the wet (or neovascular) form of macular degeneration. Neovascular macular degeneration affects about 10% of those patients who suffer from macular degeneration in general [1]. While there currently is no means of stopping or reversing the effects of macular degeneration, certain therapies (laser photocoagulation) can stem the bleeding associated with the wet form of the disease.

The effects on my father were heartbreaking in many ways. In my father’s working life he was a writer and editor for a number of industries, including the New York Medical Society, Ford Truck Times Magazine, and he was an advertising executive back in the 60s at J. Walter Thompson advertising as well as having his own advertising agency in the 1950s. In summary, my father’s sight was key to his livelihood. This was a man who used to read the New York Times cover to cover almost daily. In the last 5 years of his life, as a result of this ailment and the stroke he eventually suffered, he was left sightless and unable to enjoy the one thing that truly gave him pleasure.

I’m certain that many of us have equally poignant stories. During the 5 year period of both chronic and continuing medical care my father required I spent a great deal of time running him from specialist to surgeon to primary care physician to therapy and back again. I recall very vividly having to run him into Philadelphia from his home in the suburbs—about a 60-70 minute drive—for the purpose of having his eye surgeon review his progress. I remember how stressful the situation used to be: it was a fairly major production getting him out of the house and driving him down and back as he required assistance due to limited mobility. Oftentimes the visits were merely checkups of no more than 5-10 minutes duration. It was at these times that I used to ponder whether having a remote video and picture taking capability could have accomplished precisely the same thing: if his surgeon had the ability to review a photo remotely, my father could sit in the comfort of his home and have a retinal camera that I or another care giver could use to take a picture of his retina which could then be transmitted and reviewed by the surgeon remotely. Then, the visit could have been accomplished through a telecommunication session, in which the surgeon could speak with him directly over the telephone while reviewing the image. This would provide context for the imagery as well as provide for a much less stressful environment for my father.

Recently, Healthcare IT News reported “remote monitoring not only saves unnecessary trips to the emergency department, but prevents readmissions to the hospital” [2]. Unfortunately, the same article reports “healthcare payers are resistant to providing reimbursement for remote patient monitoring.” A chief reason for this seems to be the fact that the payer-provider reimbursement model is not adequately structured to take advantage of the benefit.

It would seem to me that the use of the technology would reimburse itself. Ignoring the time spent in traveling to and from the surgeon’s office, consider the fact that the visit itself could be shortened and accommodated on a schedule that could make most effective and efficient use of both parties: patient and provider. For example, a virtual office visit could be held at any time during the day (not just during “normal” office hours) and could even be managed from the provider’s home office. Of course, key to this would be the availability of a patient record in which information could be securely uploaded (e.g.: retinal imagery). A personal health record could have served this purpose. Furthermore, the relaxed setting of the patient’s home would have enabled a much more relaxed environment for the patient.

While the scenario I have described is not unique, it serves to illustrate a broader need and provides a compelling motive for telehealth and telecommunication. By linking healthcare information technology with existing means for communicating over telephone lines it is possible to achieve ends that will ultimately benefit chronically and elderly patients. In the next installment, I will address the benefits for other diseases, including stroke and glucose, and how the case for healthcare information technology has real benefits for the homebound or chronically ill patient.

[1] “Macular Degeneration,” http://www.stlukeseye.com/Conditions/MacularDegeneration.asp. St Lukes Eye Accessed May 3rd 2009.

[2] Bernie Monegain, “Remote patient monitoring improves outcomes for chronically ill, study shows.” Healthcare IT News. March 24^th, 2009.