Idea #71 for April 30th, 2009: Cutting Out The Pork? or Funding Pandemic Preparedness

Whether the ongoing swine flu crisis develops into a full-fledged pandemic remains to be seen. But it has already led to some political finger-pointing regarding the stimulus bill passed earlier this year. Cut from the Senate’s version of that bill was $870 million targeted for influenza pandemic preparedness, which at the time was dismissed by some as “pork.” Ironically, we are now faced with a possible influenza pandemic stemming from pork (well, swine to be exact).

It’s doubtful that any of the stimulus money would have directly affected this current influenza crisis, as not much time has elapsed since the bill was passed. Also, under the Bush administration, $6 billion was spent on stockpiling drugs to combat a possible flu outbreak. So the excision of these stimulus funds is not as troubling as it would first appear. However, it does highlight a shortsightedness on the part of Congress that is all too common. Why spend money on something that is not affecting us right now, the thinking goes.

A real problem right now, though, is the strain that swine flu response is putting on our health system in these times of shrinking budgets. Amid state budget cuts, some public health departments are shifting resources away from other concerns to tackle swine flu, the New York Times reports. Clearly, if this turns into a full-blown pandemic, the dearth of local funding would leave health departments unable to keep up with demand. Many states are in a financial crunch right now and have no choice but to cut funding across the board. But we have to make sure we have some “rainy day” funds set aside — or some other preparedness system — so that states will not have to scramble when a pandemic hits.

For more, see these articles about the pandemic and budget issues in USA Today, US News, and the NY Times.

Idea #70 for April 29th, 2009: Empty That Pill Bottle or Taking a Full Course of Antibiotics Fights Resistance

If a doctor prescribes you antibiotics for a lingering infection, you may be tempted to quit taking the pills as soon as your symptoms clear up. Doing so, though, can inflict harm not just on yourself, but the general population as well. Antibiotic resistance is a major issue in medicine, and the failure to take a complete course of antibiotics is one of several contributors to the problem.

During the initial period of an antibiotic course, the majority of vulnerable bacteria die, resulting in a marked improvement in the patient’s condition. However, a smaller amount of resistant bacteria may survive the early stages of treatment, only to multiply and return with a vengeance at a later date if the course of antibiotics is abandoned prematurely. At that point, the patient would have to switch to a different antibiotic capable of wiping out the resistant bacteria that is causing the new infection.

The concern over antibiotic resistance doesn’t end with the patient who abandons his treatment early. Such individuals breed resistant bacteria, which puts other people at risk for contracting the resistant strain. This scenario is one contributing factor to the rise of so-called “superbugs” — bacteria that are resistant to even the strongest antibiotics available. Just remember: your doctor prescribed the specific course of treatment for a reason. Abandoning antibiotics early could have devastating impacts on your health, and the health of those around you.

For more about antibiotic resistance, see information from the FDA‘s and the Mayo Clinic’s websites.

Idea #69 for April 28th, 2009: Another Case For Comprehensive Health IT or Swine Flu Epidemic

The current swine flu outbreak has resulted in 149 confirmed dead in Mexico and 48 infected in the US, according to the most recent figures. Meanwhile, the WHO raised its pandemic alert level to Phase 4, which indicates sustained human-to-human transmission. Phase 6, the highest level on the WHO alert scale, indicates a pandemic. This burgeoning flu outbreak serves as a perfect example of why we need a more comprehensive EMR and health informatics system in this country.

With today’s constant international travel and commerce, local disease outbreaks can quickly become global in scope. Our health information technology, though, is largely outdated and needs to be upgraded to ensure that data can travel as quickly as diseases. Ideally, the CDC and other agencies would have access to current, accurate data on trends that might indicate an outbreak so that they can react immediately.

As we move forward, we also have to be wary of privacy concerns. The more information available to the CDC, the better they can react to a situation, but how much patient information should they have access to? Should the medical records of everyone with flu symptoms be accessible by the CDC? These are the kinds of questions that will have to be considered when trying to balance privacy with access. One thing is clear: updating our nation’s health IT is essential for many reasons, not the least of which is disaster and epidemic preparedness.

For another take on swine flu and EMR, see this blog post from EHRScope.com

Idea #68 for April 27th, 2009: The Video Game Diet or Physical Fitness Through Wii

In the past, the only calories you could expect to burn while playing video games were those expended by moving your thumbs rapidly. Gaming has long been synonymous with inactivity, but the Nintendo Wii changed that when it was launched in the US in late 2006. Instead of relying on traditional game controllers, the Wii uses motion-sensing controllers and, for some games, a balance board that captures gamers’ movements. Thus, playing video games on the Wii involves some level of physical exertion.

With childhood obesity a major concern in this country, it is encouraging to hear that kids are burning calories while playing video games. While the health benefits don’t rival those of actual sports, active games like those for the Wii, do make kids expend three times the energy of normal games, a 2007 study showed. Also, a popular game called “Wii Fit” encourages users to become more healthful through tracking of BMI and other statistics.

Hopefully, the commercial success of these games will compel video game makers to produce more consoles and games that are wellness-centered. Schools or community centers can employ these systems to promote physical activity for children who would otherwise have no interest in fitness. Eventually, video gamers might be tempted to enjoy real fitness activities outdoors or in the gym, but until then, mimicing sports onscreen is certainly better than sedentary gaming.

Read more about Wii and your health in Time Magazine and Forbes Magazine.

Idea #67 For April 26th 2009: Not Shooting Ourselves in the Foot or The Meaning of Meaningful Use

On April 28th and 29th, the National Committee on Vital and Health Statistics (NCVHS) will be conducting hearings to collect information on the meaning of “Meaningful Use.” “Meaningful Use” is a 20 billion dollar buzzword these days because those facilities putting an EMR to “Meaningful Use” can get the incentives under ARRA/Hi-Tech, but without “Meaningful Use” you can’t. NCVHS is YAGAYNHO (Yet another government agency you never heard of) but is playing an absolutely crucial role in the practical aspects of final rule-making which will determine how the $20 billion in possible incentives gets doled out. I am quite heartened to see Fred Trotter scheduled to provide testimony and provide some general representation of Open Source systems, which now represent almost 10%-15% of the market (in patient terms), but have had little direct and public inclusion in the healthcare reform so far. Momentum is clearly building.

Historically in government policy making and in certifications like CCHIT, I think there are some significant problems that hopefully will be addressed more elegantly in this round:

• The government is not typically in the business of intentionally granting monopolies through rule-making but often indirectly does this in healthcare. If “Meaningfule Use” ends up requiring the American Medical Association’s Current Procedure Terminology (CPT), proprietary editions of ICD9/ICD10 codes, direct electronic transmittal of prescriptions (after the RXHUB/SureScripts merger only one company provides this), then they are precluding a completely Open Source offering for healthcare. If from a medical standpoint, relevant parties deem any of these absolute requirements, then there should also be a requirement that those datasets and services be available without royalty or a non-disclore agreement, both of which make it impossible for completely Open Source systems to comply. The SNOMED codeset, while not truly open, has a US national “site license” that, while not ideal, offers a good compromise between Open Source and commercial interests. I think evidence strongly suggests that is what has given SNOMED such a large base of activity and what has positioned it as the major influence on ICD10.
• There are 250,000 medical practices in the US, only about 10,000 of which have unbiased and clear representation in Washington DC. Experience tells us that there is a huge disparity between the sites that are represented in DC and most of the sites in the country. The “Meaningful Use” bar shouldn’t be too low, but if it is too high, most of the practices in the country won’t be able to meet the standard and the incentives will again be squandered. Common sense needs to come into play here and is notoriously absent in rule-making. Unless the goal is to exterminate single doctor practices, the realities of their business cases need to be considered.
• What is a good minimum starting point for meaningful use? How about digital data for patient demographics, lab requests and test results, prescriptions (not necessarily direct electronic transmittal) with optional refill requests and  history (which both require SureScripts today), scanning or data entry of critical history/clinical documents (perhaps taxonomied with a document type), a coding history, and some kind of electronic problem list. I think shooting much beyond that simple base puts it out of the reach of the majority of practices (who are still 100% paper) in the short term. Having a complete digital clinical record is a tremendously high bar for those same practices to accomplish in 2 or 3 years. Paper isn’t completely the enemy — which is somewhat against my self-interest to say — the goal here is to reduce costs and improve outcomes, and we should work backward from that. Most communications between practices don’t require the entire chart, but just a much smaller subset of information, and having that digitally available is a fantastic start.
• You can only move practices that are 100% paper today so far, so fast with a particular budget. To move to a complete digital work-flow from paper in 2-3 years would require another zero on the current incentive amount. It is much more important to solve the numerous “low fruit” problems and build clear momentum for the next ten years than it is to try and force in something for the sake of technology.
• What is “Meaningful Use” without solid Information Technology to begin with? At least 70% of all practices lack this basic foundation of modern desktops, networking, connectivity and printing. Much more focus needs to be put on general IT at health sites; health sites need to have spending in line with other industries utilizing digital workflows, which spend 5-10% of gross on IT and do not view IT purely as a cost center.  Most practices today spend under 2% of gross on IT. This needs to be reconciled with “Meaningful Use” requirements if they are going to be sustained over the long haul.
• How can we reconcile the awkward problem of patient healthiness and practice revenue? Practices that improve outcomes measurably because of “Meaningful Use” are potentially threatened because of related revenue decline. Current outcome incentives of 1% or 2% were a good experiment, but they won’t work nationally. Something much more favorable, such as outcome incentives of 5%-20% will be needed to really change habits and change entrenched but less-than-optimal best practices. Only wholesale changes will dramatically improve outcomes and reduce overall cost. The way improved outcomes are measured is perhaps the next and much more controversial battle, and “Meaningful Use” is a way to assist that debate with a common sense approach and solid starting point.

The government has a phenomenal opportunity here to express clear, concise and common sense definitions and goals that apply to, and are attainable by, 75% of practices. But if they take a major wrong turn with standards too high or too low, three years from now we will be right back here with a $20 billion sense of deja vu.

Idea #66 for April 25th, 2009: Containing Viruses Online or Social Networking Sites and Public Health

Social networking websites like Facebook have become extremely popular in recent years, and now some public health departments are using them in an effort to stop the spread of disease. In Ohio, public health workers are using social networking sites to track down partners of STD-infected patients. The focus so far has mainly been on dating sites, where members may not be aware that a sexual partner has been diagnosed with an STD.

Notifying people who’ve potentially been exposed to STDs is an important step in controlling outbreaks of those diseases. Sometimes patients know their partners only by first name or by an online moniker, which makes tracking them down difficult. That’s where the social networking sites come in handy.

In Ohio, public health workers find the patients’ partners on these sites and notify them to contact a public health facility for more information. If the patient follows up, an office visit can be scheduled to test for STDs. Aside from notifying potential carriers of STDs, public health departments also use the networking sites for education. Establishing a presence on the sites allows them to provide information and contact details to anyone interested.

To make the process easier, the National Coalition of STD Directors has published guidelines on how best to notify potential STD carriers through social networking sites. It’s great that some health departments are using current technologies to help contain the spread of disease. In Massachusetts, where similar efforts have been taking place since 2006, well over half of the people contacted have responded to notifications. As long as this is done in a way that respects privacy laws, public health departments around the country should use social networking sites to their advantage.

See news stories about social networking sites and public health here and here.

Idea #65 for April 24th, 2009: Smoke Free Pharmacy or Banning Tobacco In Drug Stores

As part of a larger anti-tobacco movement in many states, some cities have banned the sale of tobacco products in pharmacies. Notably, San Francisco and Boston have outlawed the practice, and legislators in New York are attempting to implement a similar ban statewide. The driving force behind the bans is the idea that pharmacies should exist to promote health, not damage it.

The costs of smoking — both financially and health-wise — are well known. Initiatives like outlawing smoking in restaurants and workplaces, as well as heavily taxing cigarettes, have made it increasingly difficult for smokers to keep up the habit. The risks associated with second-hand smoke make this not just an issue for individuals, but also for nonsmoking bystanders. If tobacco were not sold at drug stores, it wouldn’t put a huge dent in the overall sales of tobacco. It would, however, make it a little more difficult for smokers to access tobacco, which ultimately makes it a little more likely they will cut down or quit.

Forcing pharmacies not to sell certain products is not the ideal course of action, though. Pharmacy chains should really take it upon themselves to voluntarily ban the sale of tobacco products (if they truly believe in promoting wellness). Failing that, governments should consider taking less of a heavy-handed approach in trying to eliminate tobacco from drug stores. For instance, they could offer tax incentives to pharmacies that voluntarily cease carrying tobacco products. Cities that are banning cigarettes in pharmacies have the right idea, but need to adjust their approach.

To read more about these efforts, see the Wall Street Journal and these other news sites.

Idea #64 for April 23rd, 2009: Glucose vs. Fructose or More Reasons to Avoid Corn Syrup

As mentioned in an earlier post, corn subsidies in this country artificially lower the price of high fructose corn syrup, which has led to its inclusion in all kinds of processed foods. High fructose corn syrup is linked to more health problems than other sugars, for reasons not completely understood. New research now sheds light on the different effects fructose and glucose have on our health.

A study published this week by scientists from UC Davis investigated the effects of feeding overweight subjects drinks sweetened with either glucose or fructose. (Glucose and fructose are both simple sugars differing slightly in chemical structure, and occurring in different food sources.) After ten weeks, the subjects who drank fructose drinks had significantly higher levels of triglycerides and LDL, as well as more fat deposits in their abdomens, than those who consumed the glucose drinks. All of those health effects are known to contribute to cardiovascular disease.

Replacing fructose in our diet with glucose might seem like the logical solution, but it would be nearly impossible. Since glucose is rarely used commercially as a sweetener, it would be impractical for us to try to seek out glucose-sweetened foods. And eliminating fructose from our diet would be impossible because it is found in fruits and it’s a component of sucrose (table sugar). So what do we do? Well, even though the study did not focus on high fructose corn syrup (rather, just fructose), it would still benefit all of us to cut down on sugary drinks. And if manufacturers stopped including high fructose corn syrup in so many of their products, it could get Americans accustomed to less-sweet food. In a country where 16% of our daily energy needs come from sugary drinks, getting used to less-sweet things could greatly improve our health.

Read more about the study in the NY Times and Time Magazine.

Idea #63 for April 22nd, 2009: Fit Cities or Community Wellness Programs

There’s an interesting experiment in community health going on right now: a Massachusetts city has undertaken an ambitious plan to increase its citizens’ health, and it seems to be working. Started seven years ago in Somerville, MA in collaboration with Tufts University and the CDC, the program originally took aim at childhood obesity. At the time, 44% of their elementary school children were overweight or at risk of becoming overweight.

Under the program, unhealthy foods served at schools were replaced with more nutritional offerings, and some modifications were made to the city’s roadways to make them more bike and pedestrian friendly. Education was also stressed, including teaching kids about healthy eating choices and activities. Within a year, the schoolchildren in the study had gained 15% less weight than their counterparts in the control group.

After the program’s initial success, the scope of the movement expanded beyond the elementary school age group. All the city’s residents now enjoy more bike lanes, community gardens, improved parks, restaurants that serve more nutritious fare, and low-cost fitness classes. Dozens of other cities in the nation are following in Somerville’s footsteps, implementing their own wellness programs.

All this costs money, of course. But inactivity and poor diets are costing our nation tremendous amounts of money through obesity and all of its related ailments. The experiment in Somerville is evidence that funding projects to promote wellness can really change the culture of a community. It should serve as a model for future government spending in wellness and prevention.

See news stories about this city’s program in USA Today and the Boston Globe, and on the Tufts University site.

Idea #62 for April 21st, 2009: Striving To Be Like Minnesota or Consistent Foodborne Illness Response

I’ve blogged a few times about the FDA’s problems with food inspections and the resultant outbreaks of foodborne illness. There’s another layer of ineffective government bureaucracy at play here too, though, that needs to be reformed. The system of recognizing and stopping foodborne illness outbreaks is unorganized and riddled with problems.

The New York Times points out that Minnesota has unusually high rates of sickness whenever multi-state food poisoning outbreaks occur. The reason is not that Minnesotans are more susceptible to illness; rather it is a reflection of the state’s unrivaled reporting and response efforts to food poisoning outbreaks. Because of the diligence of Minnesota’s Department of Health, national outbreaks are often detected in Minnesota first before most other states are even aware that their populace is sickened.

Minnesota’s efforts are admirable, and worthy of replication in other states, where surveillance and response is often underfunded. For instance, while some states may pay little attention following-up after foodborne pathogens are found in patients, Minnesota health workers will conduct interviews and follow-ups with patients to uncover the source of the illness. Further complicating the matter are inconsistent protocols across different counties and states, and lack of coordination between relevant agencies.

Food products might be harvested or processed at a single site, but they are distributed across multi-state regions. We need to have an approach that addresses that reality, whereas now we have counties and states operating under disparate protocols. Since rapid response is vital in containing these outbreaks, establishing standards at a federal level would be a good first step in organizing a consistent surveillance and response effort.

Amid all this, states are slashing budgets, and surveillance programs are sometimes a causality of those cuts. When you consider that an estimated 300,000 are hospitalized yearly because of foodborne illness, those are budget cuts we can ill afford to make.

Read the New York Times’ story about this topic here.