2011 Potpourri VII

Healthcare Informatics reports on a survey regarding health information exchange use and growth.  The respondents were executives with health systems.  Most believed that the availability of HIEs would benefit patients significantly.   A centralized data warehouse was preferred over cloud structures, largely due to privacy and security concerns.  Most respondents identified the cost and governance of an HIE as major barriers to faster adoption.  Many felt the federal government should bear the cost, or health insurers.   (HIE Survey)

The Annals of Internal Medicine published a study on the effect of advance directive laws on end-of-life care.  The researchers looked at laws in all fifty states and articles on those laws.  They found that the laws had a number of problems that might prevent understanding and honoring patient preferences.  These included poor readability, restrictions on who could be an agent or surrogate and execution requirements for validity.  The study did not even note the issues of making providers and even intended agents aware of the existence and contents of a directive.   (Annals Article)

Blue Cross Blue Shield of Massachusetts reported on preliminary first year results from its Alternative Quality Contract project, which is a modified form of global payment.  According to the insurer, all groups improved quality and did so at a rate three times faster than groups not paid this way and much faster than these groups were improving before.  In addition, the plan said it was on track to reduce the rate of medical spending growth by one-half, including seeing significant reductions in misuse of the emergency room and in hospital readmissions.   (BCBSM Release)

The New England Journal of Medicine had an article reflecting on the overall issues of physician payment reform, which has been highlighted by the ongoing SGR debacle in the Medicare program.  The author notes while CMS has taken steps to try to increase the “accuracy” of the fee schedule, more work needs to be done.  The author also summarizes CMS’ actions to increase and revalue primary care reimbursement and work.  The article discusses the quality and bundled payment initiatives being undertaken by CMS in regard to physicians.  At this point, however, physician compensation by Medicare is in many ways controlled by physician organizations and still allows certain classes of physicians to make very large incomes from the program.  For a rational program to evolve, the political influence needs to be ended.   (NEJM Article)

A study published in the Journal of Medical Ethics examined the link between a physician’s own religious beliefs and intensity and how he or she handled end-of-life care for patients.  Based on a survey of 2900 doctors in England, the survey found some variation in the ethnic or religious background of doctors caring for the elderly, but that ethnicity appeared to have no relation to how they handled end-of-life care.  Non-religious physicians appeared to be more likely to take actions that they expected or intended to end life and to talk to patients about these decisions.  There was wide variation among specialties.  Helping physicians understand how their own values, perspectives and experiences may affect how they care for patients is very important to ensure that doctors really listen to and understand what the patient wants.  (Ethics Article)

The medical journal Lancet Infectious Diseases has yet another example of the dangers of guidelines.  It reports on a study on guidelines set forth by two specialty societies for the treatment of hospital acquired, health care associated and ventilator associated pneumonias.  They followed 303 patients, 129 of whom were treated in a guideline compliant manner.  This group actually had a higher mortality rate than the non-guideline compliant group.  The researchers somewhat drolly suggest that a further randomized trial might be in order before these guidelines are fully implemented.  (Lancet Article)