I've been thinking a lot recently about the state of healthcare in the United States (abysmal for rich and poor alike), and about evidence-based medicine, and how to apply the latter to fix the former. Prompt and reminder systems seem to be the key to improving healthcare in the clinic exam room and at hospital bedside. I believe the prompt & reminder system will become the "killer app" of 21st Century healthcare, revolutionizing medical practice at the grassroots level.
Disclaimer: I talk very enthusiastically in this post about a technology developed by friends and colleagues of mine and being commercialized by other friends and colleagues of mine. At present I have no financial interest in the product, but it's only because, like Butch Cassidy, "I've been working like a dog all my life and I can't seem to get a penny ahead." I think my enthusiasm is warranted, but I thought you should know my potential bias up front.
In recent months I have been working with Dr. Lee Green, a doc who teaches primary care when he's not busy delivering babies. Lee is a widely respected expert in the area ofevidence-based medicine. Over the past several years he and another doc, Don Nease, conceived of and developed a program called ClinfoTracker, a prompt & reminder system for primary care clinicians. A software engineer named Tim Morris did a lot of the heavy lifting on the programming front, but Lee and Don contributed the medical knowledge that drives the system. Don and Lee wrote it up in an article in the Journal of the American Board of Family Medicine in 2003, but the idea goes back at least to the mid-1990's. I wrote about ClinfoTracker in more detail earlier this year in response to a post in the Driving In Traffic blog about the role of Web 2.0 technologies in healthcare. I think prompt & reminder systems are important enough to deserve multiple posts, for reasons you'll understand as you read on.
The idea behind a prompt & reminder system is simple. Patients end up in the family practice doc's waiting room for many reasons, including but not limited to well-child visits, annual physicals, acute illnesses, and follow-up on secondary or tertiary care. Whenever they come in and whatever the reason, there are a lot of facts and heuristics the doc should have on her mind as she enters the examining room. These relate to the proximate cause of the visit, but also to the patient's demographics, lifestyle, employment, environmental conditions, pre-existing conditions, medications and diet. It would also be useful to have similar but less detailed information about the patient's significant others.
OK, that's the ideal. What happens in the real world? The patient's chart is in a bin outside the examining room. The clinician arrives, her mind still on the prior patient, and she looks at the chart for maybe 30 seconds as she makes the transition to the current case. If she's good at transitioning and not overwhelmed by prior events, she has about enough time to get the high points of the patient's recent history, the nurse's BP reading, and the reason for the visit before she walks into the room. If not, she acquires this information from the patient, on the fly. Either way, more often than not, she examines, diagnoses, and prescribes with insufficient information.
This scenario is arguably almost as likely to occur in an upscale setting as in an inner-city free clinic, not because it has to but because this is our standard of care. This is why we have become so good at training physicians to make decisions under trying conditions, to believe themselves at some level to be omniscient and infallible, and to do the best possible under the circumstances and move on without carrying too much baggage from prior decisions, right or wrong. It's also why we have the dismal quality of care described in the recent Rand report entitled The First National Report Card on Quality of Health Care in America. One quote that summarizes its findings:
Our study shows that everyone is at risk of receiving poor care, no matter what their condition, where they live, from whom they seek care, or what their gender, race, or financial status is.
The policy implications of these findings can be underscored by an example using profiles of two hypothetical, stereotypical patients:
- A 50-year-old white female college graduate, with private health insurance and a household income above $50,000.
- A 50-year-old black male with less than a high school education, no insurance, and a household income under $15,000.
Many would assume that the insured, female college graduate would receive substantially better care. However, given the results of our study, she would receive about 57 percent of recommended care, compared with 51 percent for the black male patient. The difference in care between these two patients is statistically significant. However, the gap between the care that each of them receives and the recommended care they should receive dwarfs the difference between them.
Not very comforting news, is it?
Let's revisit the scenario, and add one new factor. When the clinician picks up the chart and gets ready to take her 30 second look, suppose the top sheet is a summary of all the salient factors in this patient's medical and personal history. Add in the to-do items the doc herself noted the last time the patient was in the office. Top it off with up-to-the-minute evidence-based advice on the best prevention and treatment protocols that apply to this patient's situation. It's a different game altogether.
That's the advantage a prompt & reminder system provides. ClinfoTracker has been doing that for our community-based Health Centers for a few years now. I'm not a clinician, but I am a patient at one of the Health Centers, and my family physician can't imagine life without that cover sheet. My NIH Roadmap contract (of which Lee is a co-Principal Investigator) is involved in a pilot study rolling out ClinfoTracker to some primary care providers (PCPs) that take part in a practice-based research network in which our Health System participates, and there appears to be some serious competition among the PCPs to be in the first round of sites.
Docs tend to be Luddites when it comes to newfangled technology, so this level of enthusiasm is very interesting. These are docs who have signed up to do clinical research, though, and that makes them (I fear) somehat above average in their concern for the quality of care the US population is getting.
We'll soon see whether that enthusiasm carries through to the general population of PCPs. ClinfoTracker is in the process of being spun out of the University to a local startup founded by friends of mine, Cielo Systems, and will soon become manifest as a product called Cielo Clinic. (Remember the disclaimer at the top!) It may be a little while before this appears on your radar screen, wherever you are, but keep an eye out for it and give it a look when you can.
I am very curious to see if the primary care provider market is ready for products like this. Speaking personally as a primary care consumer, I can tell you that we patients are definitely ready for the quality of care that will result from their deployment.
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