Last Friday, I had an opportunity to spend part of the afternoon with Dr. Don Detmer (right) during his visit to Microsoft Research. If the name isn’t familiar, Dr. Detmer is a surgeon and the immediate past president of AMIA, the American Medical Informatics Association. He is also Professor of Medical Education at the University of Virginia. You can learn more about his distinguished career here.

As fellow clinicians and champions for greater use of ICT (Information Communications Technology) in health and healthcare, Don and I hit it off immediately. We also agreed that the missing piece in the use of ICT in clinical medicine today isn’t so much the “I” but rather the “C”. In fact, when Don talks about CT he doesn’t mean those big pieces of imaging equipment that scan your body; he’s talking about Communication and Collaboration technologies for clinical workflow.

You see, we’ve gotten pretty good at capturing data and storing it electronically. Where things still break down is in how we use that data and share it to improve care quality and patient safety and avoid the inherent costs associated with not doing so. How is all that data helping us if we don’t have equally powerful tools to make sense of it all and more importantly, to communicate what we learn across the care team and to our patients? Furthermore, how does all this electronic information we are capturing contribute to clinical research and scientific discovery?

Let me refer to something going on in my own family to illustrate the point. Two weeks ago, my elderly Aunt who seldom has headaches said she was having, “the worst headache of her life”. When it persisted after administration of the usual remedies and she also began to experience visual symptoms, I could only recommend that she immediately consult her physician or go to the ER. It was after hours and her personal physician wasn’t available so she went to the ER. The doctors there wereimage sufficiently concerned that they ordered a CT scan of her head (not the one pictured above). My Aunt was told that the CT appeared to be normal, but might not show acute thrombotic changes or very small hemorrhages. They also recommended a consultation with an ophthalmologist the next day. The eye doctor didn’t find anything wrong with her eyes, but proclaimed there was definitely something going wrong in her head. My Aunt said that her eye docotr ordered lots of blood work and told her to follow up with her personal physician. More than a week later, she’s still waiting for someone to tell her what is going on in her head. It seems her family doctor is waiting to receive information from the ER, imaging center, and laboratory. In other words, the data is available, it’s just not being communicated. Clinical workflow is broken because the community physicians caring for my Aunt don’t have the communication and collaboration infrastructure to work seamlessly as a care team.

The above is but one small example that reinforces the point on which Dr. Detmer and I so vehemently agree. It’s not so much about the “I”, it’s about the paucity of CT in clinical practice. And, I don’t mean computed tomography!

Bill Crounse 2007 05 As reported by HDM on-line, the Office of the National Coordinator for Health Information Technology has published additional information on a $598 million grant program to fund the creation of about 70 Health Information Technology Regional Extension Centers. The centers will help hospitals and physicians select, acquire and use electronic health records systems.

No doubt some serious education and hand-holding will be needed as more physicians and hospitals take the plunge into electronic medical record systems and “meaningful use”. If taking the plunge is anything like what I saw and heard during a visit to my own doctor last week, doing your EMR homework before you buy is an important step if you hope to swim rather than sink.

My doctor belongs to a very large, multi-specialty group practice. Like most large clinic systems in America this group practice, which also operates a hospital, has been using electronic records for some time. Even though the multi-specialty clinic drives most of organization’s business, they decided to purchase a health information system that is better known for running hospitals than outpatient medical centers. As long as I’ve known my doctor, he’s been complaining about the EMR system he is forced to use in the clinic.

And it’s not just my doctor who does the complaining. On my visit last week, the first thing his assistant did while checking me in was to verbally assault the blankity-blank computer system. She clicked furiously on the screen multiple times waiting for the system to respond. Just entering my vitals seamed to require clicking through endless screens. It took a ridiculous amount of keyboard work. “I hate this system”, she said. “It is always slow, especially when we are busy. And several times a day, it just goes down”.

She eventually got through all the screens and entered my data,image although I noticed that she took down my chief complaint and medication list on a sheet of paper perhaps to enter that information into the computer later. My doctor came into the room, asked me a few questions, and did a cursory exam. Mainly I was there to get some prescriptions renewed. My doctor also decided to order a few lab tests on me while I was there. On my last office visit, he had ordered lab work on the computer. This time he used a sheet paper. Before I even had a chance to say something about this he blurted out, “I suppose you noticed that I’m back to ordering lab work on paper. We tied CPOE (computerized physician order entry) but it just took too long! The clinic docs revolted, so now we are back to doing it the old fashioned way.”

Of course, I could have predicted all of this. There are much better solutions on the market for ambulatory patient care than what my doctor is being forced to use . There are far more intuitive and responsive EMR solutions. There are also solutions that are more accommodating to clinical workflow and mobile scenarios using Tablet PCs and other wireless devices. But my doctor’s group practice spent millions of dollars on what they have, and I’m quite certain they won’t be trashing it anytime soon.

So, let this be a warning. Do your homework. Select a system for your practice with the research and care you would put into making any large, really important purchase for your home or business. Don’t delegate this to your staff. It is your responsibility. You, your staff and your practice will be greatly impacted by the decisions you make. So maybe, just maybe……. a visit to one of those government funded “extension centers” would be a good idea before you take the plunge.

An op-ed piece, No Country for Old Men, filed today on The Health Care Blog by health industry consultant and futurist, Jeff Goldsmith, provides a brilliant review and excellent analysis of our past sins and possible future under health reform. Perhaps most telling is the frightening scenario he paints of doctors, especially primary care physicians, leaving the profession.

In a recent HealthBlog post that was also picked up by ABC News I provided some of my own thoughts on why "affordable" and "health insurance" shouldn't be used in the same sentence. It's really all about cost. Unless we figure out a way to substantially reduce the cost of just about everything related to healthcare (which like food is something that every one of us must consume) we are doomed to failure. But where to cut?

A lot of folks immediately point to greedy doctors. Yes, there areimage some of those, but if medical practice was so lucrative why a predicted shortage of physicians? A new MGMA survey of physician incomes ranged from a low of around $150,000 for primary care to $650,000 for neurosurgery. I don't know about you, but I want the doctor drilling into my head to be well paid. $650K doesn't seem like all that much for someone who trained for more than a dozen years and sacrificed all of his or her 20's and early 30's learning a trade. Likewise, $150K seems inadequate for people making life and death decisions after a minimum of 8 years of very expensive, post graduate education. Heck, they don’t even come close to qualifying as “needlessly wealthy” which has been defined by some people as those earning more than $250K per year.

I do know one thing. These days even the "needlessly wealthy" are having trouble saving for retirement, paying for college, and funding their future healthcare needs. To the idea of a public healthcare plan that would let me retire before I become eligible for Medicare and also be affordable, I’d say “sign me up”! The problem is, the math just doesn't figure without passing along much of the burden to someone else. And I just don't know who that someone else is going to be.

Our present health system doesn’t “scale” for lots of reasons; access and cost among them. Technology can help. If a unit of health service can be delivered by telephone, e-mail, web visit, home test, home monitoring, retail medical clinic, or visiting nurse as a less costly or more efficient alternative to traditional office or hospital services, we should encourage it. Organizations like Group Health, Kaiser, UPMC, Geisinger, and Mayo are already paving the way. The health industry is ripe for disruptive innovation. What’s needed are the appropriately aligned incentives that will move us in that direction.

It is becoming harder and harder not to recognize the part that heredity plays in the role of alcoholic propensity. Studies clearly have shown time and time again that the child of an alcoholic parent is 3 to 4 times as likely to have problems later on in life with alcohol abuse, and that the younger a person takes their first drink, the higher this risk is than in children of non alcoholics who start drinking even earlier in life. The fact that heredity play a major role in the propensity to abuse alcohol or other drugs not a reason to exclude the fact that there are other factors also, that play a role in the development of the disease and the behaviors undertaken by the person with these risks.

There are actually three roles in a person’s life that contribute to the successful management or susceptibility to falling prey to addiction:

Lifestyle and social choices- A person who never takes their first drink will not have to deal with the physical addiction of the disease. If a person is not exposed to alcohol, or chooses not to expose their body to it, then disaster is preemptively avoided. In homes where drinking is the common thing to do this can be much harder and thus the second influencing factor on addictive behavior, environment.

Children who grow up around binge drinking, drunkenness, or otherwise irresponsible alcohol or other drug use, whether in the familial or social environment are more likely to consume alcohol or other drugs than those in drug and alcohol free environments. There are exceptions to this rule, but a permissive atmosphere, or an environment where alcohol education is insufficient but supply of alcohol apparent tends to favor alcohol abuse more readily than other environments without such factors.

A family history of alcoholism is a sure sign that a person may be at higher risk of falling into alcoholic patterns. If your parents are/were alcoholic, the chances of you developing alcoholism are 3-400% higher than in non alcoholic families, and 200% higher if alcoholism was present in the previous generation. These numbers are astronomical, and though heredity cannot be controlled, hedging your chances of avoiding trouble for your kids by providing good lifestyle choices as well as a healthy atmosphere are controllable. We can’t just sit back and blame it all on nature. As parents it is our job to nurture our children.

The gap between the amount of sleep we get and the amount of sleep we need seems to be widening. When we are infants, we somehow managed to get the 16 hours of sleep our bodies required for development, and as we got older, first as restive teenagers and young adults with more important things to do after the sun goes down than to spend it dreaming, even though our bodies ask for 9 hours, and then later on in life where getting sleep is now viewed as a challenge, even though we have a slower social life and require slightly more sleep than when we were younger to feel rested. Over half of all older adults report frequent and even chronic inability to sleep. Insomnia and sleep apnea are much more pronounced in older populations, and the devastating effects of both are felt more by this group and their ability to recover from sleep debt much slower and less complete.

Lacking in adequate sleep is not just an inconvenience or minor irritant, it can also be the sign of a serious health problem, or the cause of one if left unchecked. If our bodies do not get enough rest, several of our body’s systems can become imbalances, and the immediate effects of sleep deprivation on motor skill ability and reaction times can take an otherwise safe and sane individual and turn them into a 2 ton loaded gun if put behind the wheel of an automobile in that state. Approximately 2000 people are killed every year in sleep related car accidents, and numerous other work related injuries and health problems can be associated with lack of sleep as well.

Without the ability to rest and reset all of its switches, the body will soon begin to shut down, efficiency is lost, and mental alertness can eventually come to a halt. The average adult male needs approximately 7-10 hours of sleep each and every day for optimal performance. While this is usually easily accommodated, certain sleeping disorders as well as a stressful lifestyle, and other factors such as alcoholism or drug abuse can interrupt sleeping patterns or interfere with the proper chemical reactions that take place in the brain to allow healthy rest. Certain medications can also interfere with sleep and either produce drowsiness or insomnia when taken. Diet can also play a factor. Getting your nightly rest is crucial to your health and safe physical and mental activity.