–Deep Ramachandran, M.D.
If you’re reading this, chances are that you are familiar with EPIC EMR, as well my ongoing love/hate thing with EMR’s since I first started writing about them a few years ago.
If you recall, I called most early EMR systems “overpriced, sub-standard, half-baked systems designed by polytech school dropouts”. Ok, so maybe that was a bit harsh. Continue reading “EMR Review: Epic EMR 2017”
I’m back at it again, talking about my continued love/hate relationship with EMR’s. From my conversations with doctors at different hospitals in our region, it seems that most docs appear to be falling into the “hate” column. Meanwhile, I’m still chugging along with the Allscripts Professional EHR that’s been installed in my office. And while it works just fine for the needs of a 3 physician single-specialty outpatient practice, it’s hardly the type of technology that, by itself, can change medical care for the better for a large number of people.
A recent study challenges that notion. In a study published in Chest, researchers in England sought to determine if inhaled steroids are a risk factor for pneumonia among asthmatics. It has already been shown inhaled corticosteroids are associated with an increased risk of pneumonia among patients with COPD. To determine this they looked at a database of medical information known as The Health Information Network (THIN).
In the UK, EMR’s have been in use for years, and general practitioners are encouraged (but not required) to participate in THIN. When a general practice elects to participate in THIN, software is installed in their EMR which runs in the background. The program collects data, while de-identifying it. The anonymized data is then uploaded to THIN, where approved researchers may have access to it. There is no cost to the practices for participating, and in return for their participation practices not only receive in depth practice metrics, they also receive a percentage of any research revenue generated from the use of the THIN data. At the time that the study was conducted, the database contained data from 9.1 million patients.
But back to the question at hand. From a cohort of 359,172 people with asthma the researchers were able to identify 6857 people with pneumonia, along with 36,312 control subjects. They were thus able to find a positive correlation between inhaled steroids and pneumonia. (for more on these findings, see my previous post: ) Continue reading “A Dream About U.S. EMR’s; A Reality in th U.K.”
Mail order pharmacies like Express Scripts and Medco have become increasingly prominent players in health care. But these companies are a lot more than simply mail order pharmacies, they are in fact a new generation of pharmacy benefit managers (PBM’s). PBM’s are essentially middle-men between insurance and pharmacy, with companies like Express Scripts merging the dual functions of a PBM and pharmacist into one. PBM’s manage and administer medication benefits for insurance companies. The largest insurance companies contract with them not only to manage the medication benefits of their clients (that would be you), but also to contain costs. Since insurance companies are not in the business of directly managing pharmacy services themselves, they contract with PBM’s to coordinate and manage their patients’ insurance benefits for them. If a PBM can do that at a lower cost, they save (make) money for themselves and the insurance company.
Mail order pharmacies are in a unique position to do this, as they don’t have to maintain brick-and-mortar outlets, and can use the mail to reduce costs . With such an advantage in cost containment, mail order PBM’s are quickly pushing traditional brick and mortar outfits to the periphery (remember Netflix vs. Blockbuster?). Mail order pharmacies are thus becoming giants in this industry. In 2012, Express Scripts completed a $29 billion acquisition of Medco, to create the country’s largest PBM, a publicly traded company with $100 billion in annual revenue.
Continue reading “Why I Stopped Working with Express Scripts”
I’ve written several times before about my love/hate status with my EMR. While I enjoy using mine, I long for it’s usefulness to get to the next level. While the EMR is useful at tracking data, it’s greatest handicap right now, is that it can’t talk to other systems. Data is still locked in individual systems and can’t be shared across platforms. This lack of inter-operability has thus far been the EMR’s greatest handicap, and I have longed for the time when EMRs are able to share data.
But as I see more and more systems being employed in my area and talk with other physicians about their experiences, I am becoming increasingly concerned that the inexorable march forward is going too quickly.
Shouldn’t we get these systems right before introducing interoperability into the equation?
The administration and the public are now clamoring that the information in these systems should be able to be shared among providers. In effect, that the information should not be “held hostage” by each providers respective system. These are fair and reasonable requests that should be expected in the long run. To that end, some EHR vendors have agreed in principle to begin writing standards that would allow inter-operability between systems.
The unfortunate problem here, and one that the public does not understand, is that these systems are not like the computer operating systems that they accustomed to using. It’s easy to forget that Microsoft, Word, Windows, Powerpoint, and Macs are more than 20 years old. They’ve gone through several generations and hundreds of billions of dollars in development by the worlds most talented programmers. All to now finally be at a point where the program does not routinely stop working for some unknown reason. Continue reading “Should EMR’s Be Able To Talk to Each Other?”
If you don’t know this about me by now, I need to confess something, I’m a bit of a geek. I love Star Trek (all of em), and I regularly check the NASA website to see how the Voyager pairs are doing. And yes, of course I follow the Mars rover’s twitter feed, who wouldn’t?. So as I was perusing my issue of Chest recently, there was a study that really got my attention. It wasn’t only because of the incredibly important issue of Cystic Fibrosis and identifying what causes exacerbations. It was the novel way that the authors identified air pollution as a factor that contributed to CF exacerbations.
Air pollution has long been thought to play a role in leading to lung disease. Air pollution is also thought to contribute to exacerbations in people with known lung disease such as asthma, COPD, and Cystic Fibrosis. However, these correlations have been difficult to show, and have primarily depended upon looking at admission rates for people with exacerbations of lung disease during periods where there is a known environmental anomaly or excess pollution. Unfortunately such conditions are not very predictable.
A study published in this month’s issue of Chest showed an intriguing relationship between air pollution and exacerbations of cystic fibrosis. What was intriguing to me about this study was not only that the authors showed a relationship between CF exacerbations and environmental pollution, but also how they set about demonstrating an association between the two.
They first went back and identified 2204 individual CF exacerbations that occurred at their institution in Belgium. Using the patients’ home addresses, they calculated concentrations of particulate matter, ozone, and nitrogen dioxide the patients would have been exposed to around the time of their exacerbations. Continue reading “The Relationship Between Cystic Fibrosis Exacerbations and Environmental Pollution.”