ER Visit Cost Reduction Theory; Patient "Web Searchers"

I get a lot of eNewsletters sent to me about healthcare IT and innovation - and there are often articles which catch my eye (AWCME).  They might talk about an interesting study or person, and when I read them I have some immediate thoughts because it resonates with my experiences or thinking in some way.  I'll sometimes do a quick post to FB or twitter so I can track the stories, but I've never been great about blogging on them since it takes extra time... but I'm going to try and get a little better at it.  So this will be the first edition of Articles Which Catch My Eye (AWCME)!  I will provide summaries of the article and then my "biased thoughts" (being a PCP, IT-savvy, Innovation promoting doc)!

A Novel Approach to Identifying Targets for Cost Reduction in the Emergency Department

(Link to the article in the Annals of Emergency Medicine)

A Modern Healthcare story on this article summarizes: "To maximize cost savings, hospitals and health systems should focus on reducing avoidable patient admissions to the hospital from the emergency department rather than on preventing non urgent emergency department visits… Researchers with Boston's Beth Israel Deaconess Medical Center and Harvard Medical School argue that more money can be saved by reducing the number of patients admitted to the hospital from the ED because there are no other good care options for them at the time or because a patient's complex chronic conditions were not treated properly. The researchers estimated that minor injuries and illnesses accounted for 12% to 40% of ED visits but only 0.4% to 1.6% of overall healthcare expenses, so even reducing these visits by 50% would result in savings of less than 1% of costs. On the other hand, patients with intermediate or complex conditions account for 31% to 57% of all ED visits.

MY THOUGHTS:  One on hand, I love that they did this relatively logical analysis on the stats (and it's amazing how rarely this is done in healthcare - other industries live and die by these types of stats, of course they also have an incentive system which is more consistent than our hodgepodge).  And their findings make sense: that even if the "low acuity visits" are high volume, they don't cost that much - so don't worry about them - just focus more on the high acuity visits.  However, this is where I think they missed the big picture.  IF we actually spent a bit more time figuring out how to deal with the low acuity visits (e.g. a free Primary care clinic next to the ER; or even machines which dispense antibiotics based on a few questions) - then we'd actually have much more time to spend on the high acuity patients, making it more likely they won't get admitted.  In other words, instead of thinking about absolute value, we need to look at this equation with the understanding that a given physician or ER has a limited amount of time and "cognitive load" they can use... so let's create a system where the top people (doctors) are focusing on the sickest people, and we create a system which automates or appropriately delegates lower acuity visits to other members of their health team. 

The Prepared Patient: Information Seeking of Online Support Group Members Before Their Medical Appointments

(Link to the article in the Journal of Health Communication)

Abstract: The authors examined online support group members’ reliance on their Internet community and other online and offline health resources as they prepare for a scheduled medical appointment. Adult members of an online support group (N = 505) with an upcoming medical appointment completed an online questionnaire that included measures of illness perceptions, control preference, trust in the physician, and eHealth literacy; a checklist of actions one could take to acquire health information; and demographic questions. A factor analysis identified 4 types of information seeking: reliance on the online support group, use of other online health resources, use of offline health resources, and personal network contacts. Pre-visit information seeking on the Internet was extensive and typically augmented with offline information. Use of online health resources was highest among those who believed they had control over their illness, who attributed many symptoms and negative emotions to it, and who were more eHealth literate. Reliance on the online support group was highest among those who believed they had personal control over their illness, expected their condition to persist, and attributed negative emotions to it. Trust in the physician and preferences for involvement in decision making were unrelated to online information seeking. Most respondents intended to ask their physician questions and request clinical resources based on online information.

An iHealthBeat story on this article summarizes as follows:

Researchers found that patients were more likely to look for health information online if they (1) Believed their medical conditions were long-term; (2) Felt they had some degree of personal control over their illness; or (3) Were distressed about their medical condition.  Researchers also found that: 70% of study participants said they planned to ask their doctor questions about information found online; More than 50% planned to make a request of their doctor based on information found online; and 40% printed information from the Internet to bring to their doctor's appointment. 

MY THOUGHTS: Most of this is consistent with what I've seen - that many patients will find info online and share it with me and ask questions (although not close to 40% would print it out ahead of time).   I generally find that the online patients fall into three categories: 

1. The Worried Well: They will look online anytime they have any symptoms, and find something scary, and then make an appointment to be reassured.  This is usually the largest group, and their web activities usually drive up the volume of business.  Which may be an ironic twist as there once was an assumption that having information online would avoid visits - but that is the exception - there is often just too much information for a consumer to fully understand.  These are usually quick and easy discussions - most of these patients know they over-reacted, and just need the reassurance from their physicians. 

2. The Savvy Searcher: Someone who knows what they have and does the research to help either diagnose or manage their care better.  An example might be if I tell a patient they have high cholesterol, and they use the web to find better diets for them; or patients with a "strange problem" who identifies a possible diagnosis or new medicine to try.  These folks are very much partners in the process - and I love working with them. 

3. The Truly Tragic: People who have a very bad diagnosis (e.g. Cancer, Lou Gehrig's disease...) and then obsess about it - and look at every website they can... to the point where they often drive themselves crazy because of the immense information overload.  And the worst case scenario is that if you look hard enough, they can almost always find what they want to find - such as the side effect to a drug, or that some obscure tree root is the cure which is being hidden by the establishment.  It is important that we let these patients know they should keep us in the loop because they sometimes can go on dangerous tangents if they think everything they find online is true.  

Dr. Larry Weed is The Oracle: Medical Records Should Guide and Teach!

Dr. Larry Weed was an amazing visionary physician.  Let me start by summarizing what he started saying in the 1960s:  "We need to better organize our records, better utilize paramedical personnel and appropriately use computers" - over 40 years later, and we still haven't followed his advice very well!  But we know it's true more than ever now, and we better start moving in that direction quickly!

Thanks to the internet, much of his original work exists, and it should be mandatory reading (and viewing) by anyone developing healthcare IT software or trying to change the system in any way.  Here are some of his papers:

• Medical Records that Guide and Teach: His original 1968 paper in the NEJM explained the Problem-Oriented Medical Record (POMR) - which has since become the standard of documentation across the globe.   NOTE: Unfortunately, this system has often been incorrectly thought to mean the whole note should be in SOAP format (Subjective, Objective, Assessment, Plan) vs. having a SOAP component for each individual problem.  The result is that many notes are harder to create and read since they don't group relevant information together.  
• Managing Medicine: His 1983 book which: "Contains the best of previously-published materials on Problem-Oriented Medical Records, and explains the Knowledge Couplers which have occupied Dr. Weed up to the year 2000. Much of this material is transcribed from lectures and conversations, so it preserves the candid tone, energy, and eloquence of Dr. Weed that can usually only be experienced in person or on videotape. Illustrated, with highlights captioned throughout." (per Amazon description).
• Interview with Dr. Weed: A 2009 article written by a former student who says, "We discussed when he first was alerted to the nonscientific approach clinicians use to make decisions on patients. The rest of the interview time was spent with Dr Weed teaching me about the solution that he has spent the last 30 years designing and implementing."
• Medicine in Denial (2011) According to Dr. George Lundberg's commentary, "In 267 pages, they sharply dissect virtually every sphere of medical education and medical practice. The tenet is familiar; the need to couple patient data with medical knowledge. This is not just a critical rant; it is a detailed "how to" fix the broken system.  Specifics such as "Changing medical education from a knowledge-based to a skills-based approach" and "Information processing, clinical judgment, and the two stages of decision-making" are good examples of the original 1970s premise still awaiting mass application in this century."  You can get a PDF overview here.
• Other: "Medical Records, Patient Care and Medical Education" (1964), his first paper on the topic, and in a later paper he explains, "The Problem-Oriented System, Problem-Knowledge Coupling, and Clinical Decision Making" (1989).

Finally, I especially enjoyed this video of his 1971 Grand Rounds at Emory University (see below).  Some key takeaways from his presentation include:

• Physicians need to be guidance systems, not oracles.  
• The medical record provides the data needed to be a successful guidance system, and is critical for the best Education, Care and Research. 
• Every patient and their problems are unique - just like there are 88 keys on the piano, but millions of symphonies can be played.  
• Treating a sick patient is like a Chess game... you make your move, Nature plays her move, and then back to you.