Impact of human resources on attempts to integrate TB and HIV care in developing countries

As the other posters to this blog know, I have been living in Johannesburg, South Africa since August. I came here to work on research on improved integration of TB and HIV care in various settings.

One of my studies is on TB screening in antenatal clinics that deliver prevention of mother to child transmission of HIV services. Rather than argue why this should be done, I'll post the slides from my presentation at the Stop TB Partners' Forum in Rio de Janeiro last week (https://jshare.johnshopkins.edu:443/cgounde1/StopTBPartnersForum_CGounder_20090324_abbrv.pdf). There's a clear case to be made. What isn't tough to answer is whether we do this. What is tough is to figure out is how to get staff buy-in.

The staff of the antenatal clinics includes both nurses and lay counselors. Before my study started, I trained the staff for 6 weeks on why TB was a problem among pregnant woman and neonates, and on how to do the study. I tried to inspire them to take ownership of their patients' care, and of the care of their communities.

Before the study started, the staff revolted and ask for a raise to compensate them for the additional work of the TB study. What eventually came out was that a year earlier, the staff had been given a raise to do TB screening in antenatal clinics, but had not done so until the TB study was going to require it of them.

So the staff began to work on the study... and I have been amazed by how much we have gotten done over the past couple months. They have been a pleasure to work with. At least that was until their boss resigned and a new Program Manager started a week ago. So now they are starting all over again, demanding a raise, refusing to do TB-related activities, threatening to quit. Nevermind that everyone in the research unit got a 10% raise last week.

I could of course give everyone working on the study a bonus (if I had the extra funding available to me), but this would set a bad precedent for future attempts to integrate TB and HIV activities in the future. TB and HIV activities should be integrated, but there isn't necessarily funding available to support this goal. So how does one do it? By offering bonuses through a study, I would further weaken ability of public health programs to negotiate with and retain staff when new or additional tasks are required of existing healthcare staff.

I sympathize with the staff... they are underpaid and struggle to get by. But at the same time, their patients are suffering even more.

Benefits and Challenges to circumcision as a public health intervention

Circumcision Is Found to Curb Two S.T.D.’s - NYTimes.com

A major study came out in NEJM further strengthening the biomedical argument that circumcision can help curb STD spread - HPV2 and HIV. However as always, proving the biomedical science is only the first step - next is the implementation - here are some of my thoughts on male circumcision as a public health intervention. I will try to get around to commenting on the EMR papers in NEJM this week - which are also very important - but back to our subject, here's my thoughts:

Male Circumcision shows tremendous potential:

• The data published to date suggest that male circumcision has greater benefit than any potential vaccine investigated to date.

• An additional benefit is that male circumcision is that it is similar to a vaccine - it's a one time intervention, that does not require "routine use" such as a prophylactic pill

• Male circumcision is not encumbered by the burdens of intellectual property or patents, thus making it suitable for rapid scale-up

However, barriers exist to scale-up

• Scaling up a surgical procedure will be difficult in health economies facing health infrastructure challenges. In addition to ensuring that there are appropriate health physical infrastructure, programs will need to ensure appropriate human infrastructure o ensure the quality of the procedures is adequate

• There are tremendous obstacles that public health officials will face in attempting to overcome cultural and social barriers and stigmas

• Avoiding risk compensation is critical and complex

•There are relatively few studies that understand the "demand" for the procedure, so it is hard to develop marketing strategies for male circumcision

•Implementation funds will likely be slow to reach prevention programs due to funding cycles, lack of proven models, and limited demand

•There is a catch up cohort that will need infusion of funds upfront for service delivery, monitoring, and training until providers are trained, social norms are changed, and neonatal male circumcision prevalence increases

Religious Belief Linked to Desire for Aggressive Treatment in Terminal Patients

Religious Belief Linked to Desire for Aggressive Treatment in Terminal Patients - NYTimes.com: "“To religious people, life is sacred and sanctified,” Dr. Prigerson said, “and there’s a sense they feel it’s their duty and obligation to stay alive as long as possible.”"

Is it that the patient or the patient's family that feels a duty and obligation? I must say it generally feels like the family, not the patient, that wants to keep a patient alive...

Business rule management systems in health care

Business Rule Management Systems will become the norm, for sure - a short piece in nytimes about it -

The Doctor Will B.R.M.S. You Now - Bits Blog - NYTimes.com

It makes sense to have a technology that can process the interactions between decisions and provide real time alerts and decision making tools. The difference between the airline industry and the medical industry is the fuzziness around the logic and algorithms used to make decisions in medicine. Also doctors make so many decisions in a day that there is a blunted response to alerts - there's only so many "popups" that a person can take in a day - it becomes a "cry-wolf" phenomenon.

BRMS will actually work better on the admin side - looking at more macro trends in the hospital - real time mapping of nosocomial infections, surgical throughput, discharge times - the sort of operational data that is actionable on the admin side.

Though I know of companies doing innovative medical BRMS, I have to tell you that we're a long way from something that is useable/ friendly on the clinical front lines. And even if the private sector does create a robust clinical brms solution, when you dig into the economics, it will likely need a push from the government - sort of like wind turbines or hybrid engines - good technologies that make sense, but are too expensive to bring to market without federal support (both on the production side and consumer purchasing side)

Pricing for the uninsured

This article in the NY Times dances around a point in hospital pricing which always seemed upsetting to me. My understanding is that hospitals know they get slightly less than costs for Medicare, so they charge a bit more to commercial payors. But since they know bad debt comes almost primarily from the uninsured - bad debt are essentially unpaid bills that the hospital never receives compensation for - the hospital charges uninsured patients higher than either commercially or medicare insured patients.

A quick search and I came across this article in Health Affairs which argues that uninsured patients pay prices similar to those of Medicare patients in California. So what I've seen is different than what this piece of literature states.

Hospital pricing is a black box to me right now. Jeff, any thoughts on this one ? How do hospitals price, and do the uninsured pay more than the insured?

Wal-Mart Plans to Market System for Digital Health Records - NYTimes.com

Wal-Mart Plans to Market System for Digital Health Records - NYTimes.com

Interesting play. EClinicalWorks has really made a tremendous push on the small size physician practice. This play by walmart/ecw/dell really targets a specific segment of the physician office - the small, cost oriented, "i want to get some of that stimulus money" physician segment. most physicians will dig into this offering and see it just isn't for them. EClinicalWorks has been plagued by service reputability, and buying an EMR is not just about buying a product - it's entering a marriage with a company. Sort of like buying a car.

Anyways, just goes to show the excitement about EMRs these days.

Does EMR depersonalize medicine?

The NY Times published a very good op-ed by a Columbia pediatrician today:

http://www.nytimes.com/2009/03/06/opinion/06coben.html?ref=opinion

The author's concern is that instead of actively engaging with patients, as she did with paper charts, she is now forced to stare at a computer during visits, and conduct her history-taking in a pre-specified order determined by an EMR program. This is a real weakness of EMRs - not one that cannot be overcome, but one that many people (myself included) have not considered much.

While simply putting records online is helpful, there is a huge value in having very structured EMRs. The information doctors write in free text areas is very difficult to collect and query, unless you use natural language recognition programs. These are unreliable, though they may get better. So if you want to track diagnoses for public health reasons, measure performance of doctors, or judge the quality of care patients get, you need to have the information in a specific place. Having the BP in the vital signs section and the diagnosis of hypertension in the flow chart/problem list makes it easy to track. Having it buried in a free text note does not.

I hope that funding for EMRs will create a robust marketplace in which the best designed products thrive. Many users may focus on more obvious features of EMRs, (connectivity, decision support, etc) as well as cost, and not realize that some interfaces are better than others at allowing them to conduct their patient visit in a more flexible, personalized way.

As we rush to roll out EMRs, and invest in systems that may be in place for years to decades, it is worth considering the actual end-user experience.

Patient-Physician Connectedness and Measuring Quality of Primary Care

A few of my colleagues in the Dept of General Medicine at MGH published this interesting article today in the Annals of Internal Medicine.

Patient-Physician Connectedness and Quality of Primary Care -- Atlas et al. 150 (5): 325 -- Annals of Internal Medicine

They examined the "connectedness" patients have to a particular physician. They found that of 155k patients, ~40% were not connected to a physician. Those who were had better outcomes (and were more likely to be following EBM guidelines of care).

P4P and quality metrics hinge on the premise that patients have a "home" and a patient can be mapped back to a particular physician. The reality is that patients are constantly shifting between doctors - they are "doctor shopping", their insurance changes so they switch doctors, etc. - so it'll be important to find a way to find out which patients are truly yours versus just the occasional patient who variably sees you. And for those who are not "connected" to a physician - given the better outcomes, it'll be important to find ways to plug those patients into the system.

Anecdote - I remember reviewing my outpatient panel, and finding a good hundred patients that were "assigned" to me and I was conceivably their primary doctor, but I had seen them once (or never) over three years. I would want to know there would be a safeguard to ensure that those "fly-by-night" patients are associated with my performance, and those that I truly am engaged and actively manage are the ones that I'm being evaluated on.

The logistical challenges and realities of creating a medical home

The medical home concept is gaining traction fairly quickly. Essentially it is a clinical "home" where a patient's care would be coordinated by a primary care physician - and that physician would be paid for that coordination - thus aligning physician, health system and patient incentives leading to higher quality, lower cost care.

An interesting concept - but let's talk logistics - how many other physicians would a PCP have to interact and "coordinate" with in order to close the loop?

A recent Annals of Internal Medicine report attempts to answer that very question

Primary Care Physicians' Links to Other Physicians Through Medicare Patients: The Scope of Care Coordination

They find that for every 100 Medicare patients a physician treats, the physician will interact with 99 in 53 different practices.

Seems to me the promise of medical homes can't be realized until there is sufficient technology diffusion throughout the system to ease the burden of care coordination. And that's just a necessary ingredient, but doesn't ensure success of the medical home concept. There's just no practical way that they typical primary care physician can manage that many relationships, transfers and analyses of complex medical information in a meaningful manner without technology. And even with the technology, unless they are paid enough, there won't be an incentive for the PCP to engage in medical home programs.