News 22/07/2544

News 22/07/2544

E-HEALTH AND THE PRACTICING PHYSICIAN
The Internet is rapidly changing the delivery of healthcare services in many significant ways, read about evolving e-health applications that enable physicians to harness its power for better patient care.

PHYSICIANS WARN AGAINST ANTI-AGING THERAPIES
A group of experts on aging has issued a report questioning the validity and safety of 'anti-aging medicine.'

ANTICLOTTING DRUG'S SIDE EFFECTS CAUSED 34 DEATHS IN JAPAN
Japanese drugmaker Daiichi Pharmaceutical Co. Ltd. said on Wednesday that side effects of its anticlotting drug Panaldine caused 34 deaths in the past 2 years after some hospitals did not follow proper instructions.

E-Health and the Practicing Physician
Choose How You'll Use the Internet

Mindi K. McKenna, PhD

Introduction

There are a variety of Internet-related resources available for medical professionals, some of which are geared toward helping clinicians access or manage information. Others automate tasks and thus save time and improve productivity. This article is not intended to be a product evaluation, but rather an overview of various approaches being used by physicians. Advantages and disadvantages are mentioned and survey statistics indicating usage rates are provided when available

If you're like many of your colleagues, you probably use the Internet to view medical literature, send occasional e-mails to friends, and check your stock prices. Of course, each person's Internet use is unique, and usage trends vary among clinical specialties. According to many national surveys, physicians, in general, are selective about which e-health (Internet-based) applications they use.

Online Medical Journals

According to a recent survey of Internet-connected physicians, 88% read online medical journals.^[1] Not surprisingly, this is often done after hours and from home. Because there are generally not enough hours in a workday to accommodate research or keep up with the literature, "luxuries" like reading journal articles are typically done during leisure hours.

Some physicians still choose to read articles from print journals because notes can be jotted in the margins and journals can be easily read in places that are not conducive to computer use. But many physicians find that online journals offer distinct advantages. They eliminate the need for paper handling, which is a benefit for those with limited storage space. Online articles can be quickly and easily e-mailed to colleagues, compared with photocopying a print article, placing it in an envelope, addressing, stamping, mailing it, and allowing a few days for postal delivery. Some online journals have copyright prohibitions, but most actually encourage readers to e-mail articles to colleagues and offer a simple means of doing so. Perhaps the greatest advantage of online journals is their ability to be searched by keyword topic or author. Readers can access online information according to their needs, rather than receiving print information according to a publisher's editorial calendar.

The Web has provided us with a set of tools that meet these requirements. Many clinical databases are now available -- eg, PubMed, a service of the National Library of Medicine, which provides access to over 11 million citations from MEDLINE (Figure 1), and Ovid. Some databases are free because their operating costs are funded through government grants or advertising revenue. Other databases require a subscription fee (monthly or annual charge for unlimited usage) or charge transaction fees each time an article is viewed or printed (pay-per-view).

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Figure 1. A MEDLINE search on PubMed for the keyword "prostate cancer" produces the results above. Individual query results display article abstracts and citation information. PubMed can also conduct additional searches for related journal articles, books, and links to full-text journal articles on the Internet. The new online tutorial feature can help users to refine searches, resulting in more relevant search results.

E-mail and E-mail Updates

Once comfortable using the Internet, some physicians begin using it to communicate with peers. From its inception, the primary activity that takes place over this vast expanse of cables and connections is sending and reading e-mail. The asynchronous nature of e-mail offers great utility for busy professionals for whom telephone communications becomes an unfortunate game of "phone tag." Communicating with friends, family, colleagues, and, increasingly with patients, is easier today than it has ever been. Many physicians use the Internet to send articles to peers, share medical lectures, perform peer-reviews of journal submissions. Some physicians join online newsgroups or listserves. Newsgroups are public postings of anyone's comments or opinions (similar to a bulletin board), whereas listserves are e-mail discussions that are generally private or geared to a specific group. Some physicians use the Internet rather than the mail or fax to share patient information with consulting or referring physicians.

Keeping up with the onslaught of new medical information can be challenging. Many physicians now take advantage of free e-mail services that provide journal abstracts on topics of the recipient's choosing. The key benefit, according to proponents, is that the service is automated. The recipient sets the parameters of information for delivery and the computer notifies the recipient in an e-mail message whenever that information becomes available. Most major journals offer subscribers the option of receiving an electronic table of contents via e-mail whenever a new issue is published. Some offer e-mail newsletters with brief news articles with direct links to further information.

As the popularity of e-mail updates indicates, physicians adopt tools that are quick, easy to use, and inexpensive. New technology is more likely to be purchased and used if implementation is fast and hassle-free, inexpensive enough that it doesn't require major reallocation of resources and easy enough to use that the learning curve is minimal.

Handheld Technologies

One technology that has caught on quickly and made a tremendous impact on physicians is the handheld computer. Often called Personal Digital Assistants, or PDAs, these wireless devices can be used to look up drug dosing information and to store phone numbers and schedules. Medical students and residents have adopted handheld technologies quite rapidly,^[2] and use them to manage clinical information, for training logs, and for daily calendar and address reference.^[3] Recently, Stanford University School of Medicine announced that entering students will be required to use handheld computers.^[4]

A study by Sittig and colleagues^[5] published by the American Medical Informatics Association (AMIA) described what physicians want from a PDA. Among the most important tasks that physicians would like to perform with a handheld computer include: checking drug information and treatment regimens, viewing patient data, and looking up diagnostic codes and laboratory values.

Physicians understandably tend to prefer applications they can choose to acquire and use on their own. Purchasing a $200 handheld device can be done easily, whereas buying a system that costs hundreds of thousands of dollars, affects nearly everyone in the practice, and requires administrative approval can be a difficult and frustrating venture.

Point-Of-Care Tools

The newest trend in physicians' Internet usage is occurring at the point-of-care. The year 2000 was "the year of the handheld computer" -- widespread availability of inexpensive wireless mobile computing devices that connect instantly anytime, from anywhere, to continuously updated databases. Physicians are using these devices to confirm the appropriateness of their provisional diagnoses or care plans by quickly double-checking clinical reference data from evidence-based or best-available content sources. As more physicians' offices are investing in high-speed Internet connections, the office computer can be used as a place for point-of-care information, either from within the medical record or using online resources such as collections of evidence-based literature.

The Digital Health Record (DHR)

Many physicians are interested in and curious about Electronic Medical Record (EMR) systems, also known as the Digital Health Record (DHR). But these have been more slowly adopted in the past due to high up-front costs and complexity of implementation.

DHRs are essentially systems for entering, storing and managing patient data electronically. Advantages of these systems include quicker retrieval of patient data, the potential for greater accuracy, and elimination of the need for physical proximity to the record. DHRs can reduce or eliminate high costs of transcription and paper storage, and may increase billing and reimbursement levels as a result of more thorough documentation. In addition to its positive impact on patient care by enabling better management of individual patient records, electronic storage of standardized data can enhance the care of patients because it facilitates trend analysis, which can be used to develop care guidelines for populations of patients with similar conditions.

Some physicians have begun using new simplified versions of DHR systems. Those systems store just enough information to perform patient-specific interaction checking, electronically route a prescription to the pharmacy, or perform automatic coding and charge capture. Such systems probably aren't suitable for running a totally paperless practice, but they can enhance productivity without being excessively expensive or time-consuming to implement. In the business world, this approach is often referred to as the 80/20 rule, meaning that achieving 80% of the potential benefit is optimal, whereas trying to realize the remaining 20% requires more investment than is worthwhile.

Speech Technology

Speech technology, which offers the promise of keyboardless computing, has been on the market for a few years. Although voice-recognition accuracy rates are up and voice-to-text conversion errors are down, this technology is not yet widely accepted as a standard office tool.

Past attempts to use speech recognition often produced unacceptably low accuracy rates. The early-generation, discrete-pattern-recognition approach required users to speak slowly and enunciate clearly. Newer continuous-pattern-recognition technology allows users to speak naturally and at a normal rate. Newer computers have greater speed and processing power. Databases can store larger medical vocabularies. Software is now more sophisticated in managing complex language models used by clinicians.^[6,7]

Speech recognition has come a long way. Thanks to advances in technology, automated voice recognition is now more accurate and relatively inexpensive. Two prerequisites are a high-quality microphone and a computer with sufficient processing speed. Many physicians have cited their lack of typing skills as a key objection to DHRs. Now, several DHRs allow speech recognition as a means for entering patient data. Some physicians also use voice-activated computer commands to tell their computers to "print this page" or "go back one page" while surfing the Web.

Transcription Tools

Some physicians are neither interested nor comfortable with voice-recognition software and the editing that is required after dictating, as even a 98% accuracy rate can result in significant and time-consuming editing. Several companies now offer Web-based transcription services. The dictation process looks and feels the way it always did, but rather than being recorded on tape, words are digitally stored and transmitted to a transcriptionist or to a computer that converts the words into typed text. The transcribed document is returned electronically for review and approval.

E-Detailing: Online Drug Data

Many physicians are enthusiastically embracing e-detailing -- electronically delivered drug information that can serve as an alternative to traditional face-to-face drug detailing visits by pharmaceutical company representatives. According to a recent report conducted by Datamonitor, almost 50% of physicians interviewed would prefer e-detailing to traditional office visits (see Figure 2).^[8]

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Figure 2. Results from a study conducted by Datamonitor indicated that, of the physicians interviewed, almost 90% would like to be able to request Internet-based e-detailing information. More importantly, of that group, 50% would prefer this method to traditional interactions with pharmaceutical representatives, yet only 3% have been offered this option.^[8]

Most of the programs are self-paced and typically run about 10 minutes. They offer text and images about a drug's prescribing information and safety/efficacy record. Many end with review questions that physicians can answer to reinforce their learning. Samples often can be ordered, and physicians can request to be contacted by a pharmaceutical representative after completing the programs. Some advanced e-detailing programs use streaming video technology and Internet access, allowing physicians to interact with sales representatives remotely. This technology can be delivered directly to a handheld computer with PC-linking capability.

Continuing Medical Education

Thousands of physicians fulfill CME requirements by completing courses online. Enthusiastic physicians cite significant cost savings in terms of time out of the office, travel, and lodging expenses for attendance at live CME events. Even physicians who prefer live CME are benefiting from the Internet. They log onto directories to find CME events, using search functions that sort programs according to clinical category, disease topic, location or event date. Some physicians now earn CME credits by doing medical research online, or by submitting articles for online publication. For example, Stanford University's SKOLAR, M.D. service awards CME credits for time spent researching medical literature online or for completing a test after conducting a specific search. The American Medical Association's Council on Medical Education now awards Category I CME credits for writing peer-reviewed published articles, and considers Internet-based instruction an extension of CME enduring materials.

Patient Education and Monitoring

Few health plans give medical practices online access to patient-specific benefits information, so using the Internet to verify patient-specific formulary coverage or procedure eligibility is not currently an option for most practitioners. Fortunately, that day is not far off.

The Internet offers several approaches to patient education. Many medical practices venture into this arena simply by accessing traditional documents that are posted on Web sites, customizing them with the name of the practice and physician, and giving the printed version to patients during the office visit. Some medical practices go a step further -- they post patient education information about common conditions on their Web sites, often providing links to other online patient education resources.

Online Clinical Trial Enrollment

Some physicians take advantage of the Internet to find clinical trials in which their patients are eligible to participate, or to manage patient information pertaining to clinical studies they are conducting. Online registries list thousands of industry- and government-sponsored clinical studies that are actively recruiting and accepting new patients. These registries can usually be searched by keyword, disease, or by geographic location. Some can be searched by organizational affiliation and provide direct links to research Web sites or direct e-mail to trial investigators. Some registries offer to send e-mails alerting physicians or patients of new clinical studies in selected therapeutic areas.

Keeping Patients in the Loop

Many patients have begun asking their physicians to communicate with them via e-mail in order to receive pre- and post-procedure instructions, test results, or follow-up messages. This may sound like a time-consuming task, but several companies now offer systems that automatically capture physicians' dictated encounter documentation and transmit it in consumer-friendly language directly to patients' personalized patient web pages (Figure 3).

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Figure 3. As the quantity of electronic patient-to-physician communication increases, so does the demand for physicians' attention. While e-mail can be an effective way to handle specific patient questions, there are more efficient ways to accurately transmit lengthy and specific instructions to patients. For example, PATIENT ED® by Medifor allows physicians to create customized patient instructions that the patient can retrieve and manage via PC. Image courtesy of Medifor Inc.

Automated Internet messaging systems are now used by some physicians to send proactive reminders to their patients. For example, all female patients over age 40 may receive annual e-mail reminders to come in for a mammogram. All patients over age 65 may be reminded each fall to come in for a flu shot. Such preventive measures not only enhance patients' clinical outcomes, they financially benefit physicians if paid on a fee-for-service basis.

Web-based disease management programs are available to treat patients who suffer from chronic conditions. These new approaches offer several advantages over traditional programs. In many scenarios, patients wear monitoring devices that transmit vital signs or other clinical measures to the medical practice via the Internet. Physicians are alerted only when their vital signs are outside of ranges designated by prespecified parameters. In addition to clinical benefit for patients, these programs also offer physicians under managed-care risk-sharing plans an affordable, non-labor-intensive means of reducing costs through earlier detection and treatment.

Summary

The Internet is changing medical education and healthcare service delivery in many significant ways. Although this article focuses on leading e-health applications, there are many other ways for medical practices to take advantage of the Internet. Physicians are using Internet-enabled practice management applications, personnel management resources, and patient care services. Many practices now operate Web sites to market themselves to patients and referring physicians, reduce costs, interact with patients, and even generate new sources of income. Properly implemented and adopted, these new applications offer physicians the opportunity to harness the Internet for better patient care.

References

Manadilli M. Global Survey Points to Increasing Use of Internet by Physicians. Xpress Press. September 8, 1998. Available at: www.xpresspress.com/news/physiciansurvey.html. Accessed April 30, 2001.
Garvin R, Otto F, McRae D. Using handheld computers to document family practice resident procedure experience. Fam Med. 2000;32:115-118.
Kennedy RS. Hand held computing for psychiatry residents. Program and abstracts of the American Medical Informatics Association 1999 Annual Symposium; November 6-10, 1999; Washington, DC. Session S98-Poster 2. Available at: http://medicine.ucsd.edu/f99/D005679.htm. Accessed May 2, 2001.
Maragoni J. Med school embraces handhelds. Silicon Valley Business Ink. March 1, 2001. Available at: http://www.svbizink.com/closeup/closeupdetails.asp?iid=167&aid=1190. Accessed April 30, 2001.
Sittig DF, Jimison HB, Hazlehurst BL, et al. Techniques for identifying the applicability of new information management technologies in the clinical setting: An example focusing on handheld computers. Proc AMIA Symp. 2000;(20 suppl):804-808.
Schwager R. Speech recognition propels transcription revolution. J AHIMA. 2000;71:64-68; quiz 69-70. Available at: http://www.ahima.org/journal/features/feature.0010.2.html. Accessed April 30, 2001.
Erdel T, Crooks S. Speech recognition technology: an outlook for human-to-machine interaction. J Healthc Inf Manag. 2000; Summer 14(2):13-21.
DePalma A. Physicians want eDetailing -- so why aren't they getting it? Drug Discovery Online. September 21, 2000. Available at: http://www.drugdiscoveryonline.com/content/news/article.asp?DocID={187E5E99-8FC5-11D4-8C63-009027DE0829}. Accessed April 30, 2001

Physicians Warn Against Anti-Aging Therapies

NEW YORK (Reuters Health) Jul 16 - A group of experts on aging has issued a report questioning the validity and safety of "anti-aging medicine."

"There are no valid intrinsic measures of aging," Dr. Robert N. Butler, head of the International Longevity Center-USA (ILC), said at a press briefing here. "Claims that you hear of slowing or reversing aging cannot be proven."

Dr. Butler, who served as the first director of the National Institute on Aging, is a professor of geriatrics and adult development at the Mount Sinai School of Medicine in New York.

The ILC sponsored a workshop last week on "Biomarkers of Aging: From Primitive Organisms to Man" and released a report based on its conclusions. The workshop was one of a series on aging issues, held by the ILC twice a year, modeled on the National Institutes of Health's consensus conferences. The ILC is a nonprofit, New York-based research, policy and education organization.

According to the ILC, the American Academy of Anti-Aging Medicine states that about 2500 US doctors have established specialty practices in anti-aging medicine and claims that "immortality is within our grasp."

Dr. Butler and his colleagues counter that such claims are great exaggerations, and that neither the academy nor the specialty of anti-aging medicine is recognized by mainstream groups, including the American Medical Association.

Some physicians in the US, France and Great Britain are offering a series of laboratory tests that promise to measure a person's "actual" — rather than chronological — age, Dr. Butler said. They use these tests, which cost up to $2,000, as a basis to prescribe an anti-aging regimen of antioxidants or hormone replacement.

Dr. Butler noted that a year's supply of human growth hormone costs $15,000 to $18,000, there is no scientific evidence that this or other hormone replacement therapies will extend life, and they may in fact be harmful. "It's certainly a very fine way to make a living, unfortunately," he said.

"At the animal level, human growth hormone has been found to shorten life," he noted. "There may be an appropriate normal physiological reason why the hormone declines with age."

Dr. Butler and Dr. Howard Fillit, who heads the New York-based Institute for the Study of Aging, also assailed claims that antioxidants have anti-aging properties. "Antioxidants have never been proven to be of any clinical benefit for any illness, ever," Dr. Fillit said.

He also argued that the anti-aging movement "medicalizes" the aging process, treating it as a bad thing. "It sends the wrong message to our doctors and to our people," he said.

Anticlotting Drug's Side Effects Caused 34 Deaths in Japan

TOKYO (Reuters) - Japanese drugmaker Daiichi Pharmaceutical Co. Ltd. said on Wednesday that side effects of its anticlotting drug Panaldine caused 34 deaths in the past 2 years after some hospitals did not follow proper instructions.

The company said it had no plans to withdraw the drug but would boost education for physicians prescribing it.

Daiichi Pharmaceutical, one of Japan's top 10 drugmakers, had reported the incidents to the Health Ministry and said the deaths were partly due to hospitals' failure to take precautionary steps outlined in its instructions.

The deaths were among 394 cases of side effects of Panaldine confirmed between July 1999 and June 2001, a company spokeswoman said. She added that according to a recent survey conducted by Daiichi of 206 of the 394 side-effect cases, 76% of medical institutions failed to follow instructions on use of the drug.

In June 1999, the government instructed Daiichi and 22 sellers of the drug to issue emergency warnings to hospitals about the drug's side effects.

"We issued additional instructions to medical institutions earlier this year to take precautionary steps," the Daiichi spokeswoman said, "but we aim to reinforce the warnings to minimise cases of side effects."