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WORKING GROUPS

Working group 6: The role of technology to enhance clinical and educational efficiency

	Internet-based educational approaches can facilitate participation in CME programs

Top Internet-based educational... Electronic communication between... The electronic medical record... Electronically provided "disease... Telemedicine potential Recommendations Working Group 6 References

As Internet use by physicians has increased dramatically, it has been suggested that some of the challenges providers and consumers of CME face could be ameliorated by shifting to web-based educational materials. Meanwhile, there has been explosive growth in both traditional and online CME offerings. According to Bernard Sklar, a physician who has followed online CME trends, there were 150 CME websites offering 3,510 activities for 5,500 credit hours in December 2000. By June 2002, there were 209 sites offering 10,952 activities and 18,263 credit hours (2). Despite this dramatic growth in providers and offerings, however, online CME credits still constitute a small fraction of total CME credits awarded. According to a 2001 survey by the Boston Consulting Group, physicians are changing their online information-seeking practices. Doctors appear to be reducing the number of sites they use for medical information, and professional association sites such as the ACC's Cardiosource (www.cardiosource.com) are showing the greatest gains in use (3).

Online CME use by physicians will continue to grow as concerns and issues raised by CME consumers are addressed:

1. Online CME must become easier to find, and sponsors of it must provide better directories of the content and more information about the source of that content.
   
2. Online CME offerings must become more engaging to overcome the natural preferences of many physicians for paper-based models. This may require more development of Internet-based simulations and interactive clinical problem-solving exercises.
   
3. The CME consumers, especially those in mid-career, will need ongoing support if they are to take advantage of the Internet and other innovations in information transfer. It is apparent that competency in electronic information management will be a necessity for physicians who want to practice state-of-the-art medicine.
   
4. The role and influence of industry in CME requires further clarification, in terms of online and traditional types of educational offerings. The CME consumers must be able to determine the quality, source, and objectivity of information provided. This should be a major determinant of user preference; it also presents organizations such as the ACC with both opportunities and challenges.
   

"Just in time" education to meet the needs of practitioners providing care to patients.   It is believed that the most "teachable moment" occurs when a medical student, resident or practicing physician is actively engaged in the care of a specific patient. Information obtained in that setting is more likely to be remembered and to have a lasting impact on practice behavior. As providers gravitate toward electronic medical record (EMR) systems and computers become even more common in the hospital and office settings, the likelihood increases that physicians will have (or will demand) more access to so-called "just-in-time" learning (i.e., CME that occurs in real-time in the context of patient care). Applications that focus on this type of context-based learning are being developed. Meanwhile, evidence-based practice databases are being imbedded in various types of EMR products, such as physician order-entry and standardized order sets.

An example of "contextual" online medical information and CME is the Stanford SKOLAR MD program. Subscribers can access a number of medical reference books, full-text journals, drug databases, practice guidelines, evidence-based medicine resources and patient educational material. They can also receive Category-I credit for conducting a search and answering online questions regarding the material. It seems likely that this type of "granular CME" has the potential to increase the efficiency of obtaining CME credit and to reward physicians for using information resources while taking care of patients.

Meanwhile, trends in consumer education are affecting the content and context of communications between patients and their physicians. Many patients now use the Internet to gain insights into their health problems and treatment alternatives. Already, consumers use the Internet to obtain health information more than for any other reason (4). More people go online daily to look up health care information (6 million) than visit doctors. In 2000, the Pew Internet and American Life Project reported that 52 million Americans relied on the Internet to make crucial health care decisions; in 2002 that number increased to 73 million.

The growth and impact of direct to consumer advertising in recent years has also been dramatic. Despite these trends, many patients still prefer to receive health information directly from their physician or a member of his or her staff. One concern about patients using the Internet to seek health information relates to the reliability of what they find and read. To help physicians direct their patients to reliable health information on the Internet, the National Library of Medicine (NLM) and the American College of Physicians (ACP) are piloting an "information prescription" program. This allows a physician to provide a patient with a pre-designed prescription that takes him or her directly to high-quality health information on Medline Plus. Similar partnerships, designed more specifically for cardiologists and patients with cardiovascular disease, may be possible for the ACC.

Point-of-care education and advice via wireless devices.   The growing use of personal digital assistants (PDA) by physicians represents another opportunity for point-of-care education and interactivity. A 2002 ACC survey found that 54% of members reported using a PDA for one or more professional functions. The scope and sophistication of clinical and professional applications designed for PDAs continue to increase dramatically. The case of the free drug database application, ePocrates Rx, is instructive. This application (used by more than 100,000 health professionals) was the subject of a recent survey reported by Bates and colleagues at the Brigham and Women's Hospital in Boston (5). They surveyed a random sample of 3,000 ePocrates Rx users; 32% responded. Users identified several advantages of this program, including saving time during information retrieval, ease of incorporation into patient workflow, and enhanced decision making in drug selection and dosing. Respondents also believed their use of the database reduced preventable adverse drug events. Systems that will document the use of PDA resources as a way to receive CME credit will likely be developed. The convergence of PDAs and bar code technologies in the healthcare industry will provide opportunities to link specific information searches (e.g., guidelines) to specific patient evaluations in a way that can be used to document an individual physician's attempts to provide high-quality care.

	Electronic communication between patients and physicians

Top Internet-based educational... Electronic communication between... The electronic medical record... Electronically provided "disease... Telemedicine potential Recommendations Working Group 6 References

 
The Internet provides opportunities to improve satisfaction and outcomes by enhancing communication among patients, their physicians, and other health care providers. Just as the telephone replaced much written correspondence during the second half of the 20th century, e-mail is now replacing the telephone as the primary means of communication. Patient privacy concerns, especially in view of new HIPPA regulations, have implications for how physicians communicate with their patients. Although some practices use e-mail for patient communication, this may be more problematic if the messages are not encrypted for privacy. Moreover, the communication is not just between a single patient and his or her private physician. Many practices now rely on non-physician clinicians or other staff members to inform patients of laboratory results or to help educate them. The majority of cardiologists now practice as a member of a group, and team care offers many advantages, as discussed by Working Group 5. These important innovations make it necessary to focus on the security of patient information that is transmitted electronically.

The impact of e-communication will vary depending on the balance between health care practitioners "pushing" information to patients and patients/consumers demanding or "pulling" information from health care providers (6). Kaiser, the large California HMO, has a members-only consumer website designed to give members an alternative to calling or visiting their physician or other health care provider. The service includes health-learning materials, health assessment tools, and links to selected health-related sites. Patients can also communicate with other members, Kaiser staff, and physicians.

Although e-mail is now the preferred method of communication among friends, family members, and colleagues, anecdotal information suggests that physicians are reluctant to use e-mail for patient correspondence because they are concerned about the volume of messages they may receive from patients or concerned family members. Moreover, there is no reimbursement for e-mail (or telephone or written) advice. Still, using e-mail to answer patient questions and/or to provide educational materials could reduce the amount of "communication time" with patients, as direct telephone conversation may be lengthy compared with more succinct replies via e-mail. Written messages to patients could enhance the ability of patients to follow instructions.

Tools that provide information that supports self-care and decision making by patients may ultimately reduce demand for unnecessary services (7). For a significant transition from face-to-face visits to online communication between physicians and patients to occur, however, reasonable reimbursement for the services provided electronically must be established. Recently, Blue Shield of California made a decision to reimburse physicians for time spent providing online consultations for patients via e-mail (8).

Another approach used by some medical practices is to establish a Website with a secure connection for health care providers and patients. The VeriSign Secure Site, or similar programs that employ security measures akin to those used by banking and e-commerce sites on the Internet, enhance the privacy of submitted information. The establishment of such a secure site is likely to be cost-effective for many practices that want to communicate with patients in a secure fashion. This may reduce costs and increase convenience because a patient can receive information from his or her physician about test results, treatment options, and prescriptions without actually visiting the doctor's office. In contrast to e-mail, this form of secure e-communications addresses privacy issues that are of such concern in contemporary medical practice. There are many potential uses for and advantages of such a system for patients as well as physicians and members of their staff. These include:

1. Prior test results are available, making it possible to review trends (e.g., lipid levels, glucose levels, internal normalized ratios, weight, blood pressure, etc.).
   
2. Some EMR packages offer the ability for real-time transfer of laboratory results between facilities. After review and added comments, the information can be transferred directly to the patient's personal "mailbox."
   
3. Reminders can be e-mailed to patients who require a follow-up visit or laboratory tests.
   
4. Patients and medical staff can communicate about symptoms and questions.
   
5. Patient appointments can be scheduled or rescheduled online with automated programs that respect patient convenience and reflect provider availability.
   
6. Electronic claim submission can facilitate timely reimbursement.
   
7. Patients can review the status of their bills and insurance payments. They can also arrange for electronic fund transfer to pay for services they have received.
   
8. Patients can subscribe to newsletters that provide general healthcare information, news about new services offered by the practice, or information about clinical trials.
   
9. Links can be created to other sites that provide information that might be useful to patients and their families.
   
10. Patients or other authorized individuals can access all or portions of the medical records anytime, after appropriate approval and authentication.
    
11. Prescription renewals can be forwarded electronically to specific pharmacies that have established systems to handle this method of communication among patients, physicians, and pharmacists.
    

	The electronic medical record (EMR)

Top Internet-based educational... Electronic communication between... The electronic medical record... Electronically provided "disease... Telemedicine potential Recommendations Working Group 6 References

 
Although a minority of physicians currently use an EMR in their outpatient practices, this method of documentation and communication will play a vital role in the future of health care (9–11). The EMR offers several advantages to individual physicians, group practices, and hospitals. Ideally, it should be comprehensive and include links to all relevant patient information such as outpatient and inpatient notes, laboratory and X-ray results, and procedure and pathology reports. Such connectivity has the potential to increase the efficiency of the physician and the health care team by facilitating data retrieval and the coordination of care and follow-up. The relative ease of accessing patient data should facilitate decision making. Finally, an optimal EMR should enhance the quality of care delivered and the outcomes of that care. Although no single EMR has emerged as superior to all others, the EMR developed for the Veteran's Affairs hospital system is one of the most integrated and sophisticated in existence.

The EMR is considered to be an essential tool to improve health care efficiency and enhance outcomes. Nevertheless, obstacles such as cost and resistance to change have delayed its widespread adoption (12). A recent survey of 1,587 physician organizations showed that clinical use of information technology (IT) systems for electronic data capture was inconsistent (13). When asked if their electronic data system included a standardized problem list, progress notes, medications prescribed, medication decision support, laboratory results, and radiology results, the average physician organization had only 1.4 (23%) of these six capabilities; 49.9% had none and 78.5% had two or less. For the immediate future, partial integration of EMR systems is likely to limit the attainment of potential efficiencies on physician workflow. Utilization of EMRs in health care will be imperative to consolidate patient data efficiently and to optimize the display of relevant clinical information used to make medical management decisions. After a steep learning curve, the EMR should improve overall productivity and practice efficiency.

The ability to enter relevant patient care information at the bedside quickly and accurately should enhance patient care and improve outcomes. Physicians and other providers can become more efficient if they can enter or access data at several convenient locations in the hospital or outpatient setting. Key findings and progress notes can be entered at the point of care and transferred to the hospital record and/or a provider's EMR through a wireless network. Palmtops and PDAs are being used increasingly as a point-of-care tool. Software applications that are particularly useful to physicians include patient tracking, laboratory order entry and results checking, medical calculations, prescription writing, and charge capture (14). Providers can also monitor real-time data via a Web browser or wireless application (15). Potential efficiencies include the avoidance of duplicative efforts, enhanced decision making, and reduction in workload for physicians, non-physician clinicians, and other personnel. Problems with legibility of progress notes would be eliminated, reducing potential errors and saving time for other medical personnel involved in the patient's care.

Point-of-care technology includes the use of palmtops not only to retrieve patient clinical data, but also to retrieve important scientific information useful in patient care and decision making. As mentioned earlier, ePocrates is an example of medication software that provides ready access to information on cost, dosing, drug interactions, and adverse reactions (16). A survey of physicians using ePocrates Rx revealed that this tool facilitated information retrieval, was easily incorporated into the workflow, and improved the quality of decision making (5). Although many physicians use PDAs, only 4% were estimated to use them for writing prescriptions (17). It is likely that electronic prescription "writing" will replace the traditional handwritten prescription because it can facilitate documentation and communication and reduce errors (18). Barriers must be overcome to encourage the widespread utilization of these tools. A 2001 Harris Poll showed that 26% of physicians used PDAs, but this number is expected to double by 2005 (19).

Computerized physician order entry (CPOE) has also been demonstrated to improve quality and reduce resource utilization; but many studies suggest it takes longer to enter orders (20). One study showed that physicians in training spent 9% of their time on CPOE functions compared with 2% with paper order entry. Some of the increased time spent on CPOE can be counterbalanced by decreased time used by other personnel such as pharmacists and nurses.

Rapid electronic retrieval of laboratory, pathology, and radiology reports.   The ability to retrieve clinical information promptly plays an integral role in optimizing decision making and providing quality care. The near instantaneous electronic acquisition and/or display of data at the physician's fingertips can substantially reduce the time of an office visit. Commercially available computer systems make it possible to view pathology specimens, radiology films, and other imaging studies from any computer workstation in a hospital or other integrated practice location. This eliminates the need to visit the laboratory or X-ray department to view studies, which, in turn, should increase the likelihood that the ordering physician will review the actual images rather than rely entirely on written or verbal reports.

In a study of so-called picture archiving and communication systems (PACS), referring physicians unanimously preferred PACS over film, and 91% of users believed they increased their productivity (21). Integration of a PACS into an EMR maximizes efficiencies in the system (22). Extending the ability to view imaging tests electronically to a physician's office can further enhance efficiency and productivity. Remote viewing of imaging studies also makes it possible to show patients and family members the actual echocardiogram or angiogram images used to make treatment decisions.

	Electronically provided "disease management" guidelines

Top Internet-based educational... Electronic communication between... The electronic medical record... Electronically provided "disease... Telemedicine potential Recommendations Working Group 6 References

 
Prompt access to current and relevant scientific evidence has become increasingly important in the clinical decision-making process. The body of knowledge in medicine is expanding at an explosive rate (23). Clinicians cite time constraints as a major reason they do not seek answers to questions that may be relevant to patient management (24). Textbooks and journals may not be readily available. Evidence-based clinical practice guidelines have become a mainstay in cardiology and many other specialties. Although authoritative guidelines such as those produced by the ACC and AHA can inform medical decision making, the creation and distribution of guidelines does not ensure their use (25). To be most helpful, guidelines must be in an accessible format that is easy to use and up-to-date.

A recent physician survey showed that 68% had received guidelines from health plans and 57% had access to disease management (DM) programs (26). Eighty-five percent of generalists and 71% of specialists found clinical guidelines useful; 83% of generalists and 74% of specialists found DM programs useful. By enhancing quality of care through better adherence to guideline recommendations, it is also possible that reductions in health care utilization might occur, thereby reducing unnecessary scheduled patient visits, phone calls, and hospitalizations.

	Telemedicine potential

Top Internet-based educational... Electronic communication between... The electronic medical record... Electronically provided "disease... Telemedicine potential Recommendations Working Group 6 References

 
Telemedicine is defined as facilitated remote consultation and diagnosis using telecommunication technologies. The primary rationale for the development of telemedicine is to serve populations that, for various reasons, have limited access to traditional, high-quality diagnostic or therapeutic medical services. Although telemedicine lends itself particularly well to specialties where images are crucial to diagnosis, such as dermatology, it is used effectively by many specialties. Two modalities are available for using telemedicine: 1) store-and-forward and 2) real-time.

In the "store-and-forward" approach, clinical images (e.g., information derived from an examination or a procedure) are sent to another site for display, interpretation, and permanent storage. The advantage of the store-and-forward technology is that it obviates the need for simultaneous availability of the consulting parties. The low bandwidth requirements for this technique also make it less expensive. The store-and-forward format is appropriate when a formal report is not required for immediate decision making. A much more demanding telemedicine approach is the "real-time" transfer of an examination record so that two (or more) caregivers (and a patient) in different locations can simultaneously assess the results provided by the imaging examination. Logistical issues such as scheduling all the parties at the same time and accessing bandwidth on demand have limited the use of real-time telemedicine.

Meanwhile, development of the Digital Imaging and Communication in Medicine (DICOM) led to the acceptance of a standardized format and media (CD-ROM) for archiving, exchanging, and transferring images. The acceptance of the DICOM standard means that coronary angiograms can be viewed in different institutions and over time (facilitating comparison with prior studies). With the availability of the standardized DICOM format, in addition to the image acquired at the site of procedure (e.g., a community hospital) the images can be displayed at a remote site (e.g., a tertiary referral center). In interventional cardiology, for example, this approach is an excellent tool for education and practice.

In contemporary cardiology practice the most common application of telemedicine is the transmission of electrocardiograms. It has been shown to be especially effective in pediatric cardiology, where the prompt and accurate diagnosis of congenital heart disease in the neonate may be crucial to the outcome of the patient (27,28). One benefit of the telemedicine link is to be able to provide a remote diagnosis from transmitted images to help decide whether and when patient transfer is indicated. Telemedicine can enhance patient care and inform decisions with respect to the need to transfer patients from community hospitals to referral centers.

The use of telemedicine in the catheterization laboratory is still in its infancy. There are four important areas of potential application for real-time catheterization procedure data transfer: 1) physician training, 2) clinical conferencing, 3) support for clinical trials, and 4) support for clinical procedures. Except for clinical conferencing, the other applications require accurate replication of angiographic, echocardiographic, and intravascular sound data. This would require high-fidelity, and higher bandwidth telecommunications systems. The cost of such systems may preclude the routine use of telemedicine in cardiology at the present time. Telemedicine holds much promise for cardiology practice, but some important issues need to be resolved (e.g., reimbursement, licensure, and HIPPA) before it can achieve its full potential.

	Recommendations

Top Internet-based educational... Electronic communication between... The electronic medical record... Electronically provided "disease... Telemedicine potential Recommendations Working Group 6 References

 

1. The ACC should play a leading role in the effort to develop and implement functional requirements and characteristics of cardiovascular information management systems.
   
2. The Accreditation Council for Graduate Medical Education (ACGME) should endorse and implement new models of point-of-care learning and continuing medical education.
   
3. The expanded use of high-quality telemedicine to supplement traditional cardiovascular care to all appropriate patients and communities should be encouraged.
   
4. The ACC should help educate cardiovascular specialists about existing and emerging technologies that can improve the quality and efficiency of patient care.
   
5. The Internet and other new technologies such as PDAs should be used to facilitate the dissemination and implementation of clinical practice guidelines.
   
6. New technologies such as e-mail and other Internet-based functions should be used to enhance cardiac care team-patient communication, education, and disease management.
   

	Working Group 6 References

Top Internet-based educational... Electronic communication between... The electronic medical record... Electronically provided "disease... Telemedicine potential Recommendations Working Group 6 References

 

1. ACCMR Annual Report Data 2002. Accreditation Council for Continuing Medical Education. Available at: http://www.accme.org/incoming/156_2002_Annual_Report_Data.pdf. Accessed February 13, 2004
2. Sklar BM. Online CME—An Update. Available at: http://www.cmelist.com/resule.htm. Accessed February 19, 2004
3. Silverstein MB, Lovich D, Von Knoop C. Vital Signs Update: Doctors Say E-Health Delivers. 2001. Boston Consulting Group
4. Fox S, Rainie L. E-patients and the online health care revolution. Physician Exec. 2002;28:14–17[Medline]
5. Rothschild JM, Lee TH, Bae T, Bates DW. Clinician use of a palmtop drug reference guide. J Am Med Inform Assoc. 2002;9:223–229[Abstract/Free Full Text]
6. Seror AC. Internet infrastructures and health care systems: a qualitative comparative analysis on networks and markets in the British National Health Service and Kaiser Permanente. J Med Internet Res. 2002;4:E21[Medline]
7. Robinson TN, Patrick K, Eng TR, Gustafson D. An evidence-based approach to interactive health communication: a challenge to medicine in the information age. Science Panel on Interactive Communication and Health. JAMA. 1998;280:1264–1269[Abstract/Free Full Text]
8. Containing Costs While Maintaining Quality. Drug Benefit Trends. April 29, 2004. Medscape. Available at: http://www.medscape.com/viewarticle/447793?mpid=9737. Accessed February 3, 2003
9. Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in U.S. primary care. J Am Med Inform Assoc. 2003;10:1–10[Abstract/Free Full Text]
10. Weber D. 25 Health care trends. What's hot, what's not, and what does the future hold. Physician Exec. 2003;29:6–14[Medline]
11. Terry K. EMRs boost efficiency, too. Med Econ. 2002;79:38–4043[Medline]
12. Agrawal A. Return on investment analysis for a computer-based patient record in the outpatient clinic setting. J Assoc Acad Minor Phys. 2002;13:61–65[Medline]
13. Casalino L, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA. 2003;289:434–441[Abstract/Free Full Text]
14. Sausser GD. Use of PDAs in health care poses risks and rewards. Healthcare Financ Manage. 2002;56:8688
15. Pollard JK, Fry ME, Rohman S, Santarelli C, Theodorou A, Mohoboob N. Wireless and Web-based medical monitoring in the home. Med Inform Internet Med. 2002;27:219–227[CrossRef][Medline]
16. Epocrates. Available at: http://www2.epocrates.com/index.html. Accessed April 23, 2004 and July 10, 2003
17. Firms Push to Have Doctors Abandon Pen for PDA. USA Today June 24, 2001
18. A Call to Action: Eliminate handwritten prescriptions within three years. Institute for Safe Medication Practices (White Paper, 2000). Available at: http://www.ismp.org/MSAarticles/WhitepaperPrint.htm. Accessed July 10, 2003
19. Medscape from WebMD. Available at: www.medscape.com/view. Accessed March 18, 2001
20. Shu K, Boyle D, Spurr C, et al. Comparison of time spent writing orders on paper with computerized physician order entry. Medinfo. 2001;10:1207–1211[Medline]
21. Chan L, Trambert M, Kywi A, Hartzman S. PACS in private practice—effect on profits and productivity. J Digit Imaging. 2002;15(Suppl 1):131–136
22. Siegel EL, Reiner BI. Filmless radiology at the Baltimore VA Medical Center: a 9 year retrospective. Comput Med Imaging Graph. 2003;27:101–109[CrossRef][Medline]
23. Masys DR. Effects of current and future information technologies on the health care workforce. Health Aff (Millwood). 2002;21:33–41[Abstract/Free Full Text]
24. Cartwright J, de Sylva S, Glasgow M, Rivard R, Whiting J. Inaccessible information is useless information: addressing the knowledge gap. J Med Pract Manage. 2002;18:36–41[Medline]
25. Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ. 1997;157:408–416[Abstract]
26. Christianson JB, Wholey DR, Warrick L, Henning P. How are health plans supporting physician practice? The physician perspective. Health Aff (Millwood). 2003;22:181–189[Abstract/Free Full Text]
27. Julsrud PR, Breen JF, Jedeikin R, Peoples W, Wondrow MA, Bailey KR. Telemedicine consultations in congenital heart disease: assessment of advanced technical capabilities. Mayo Clin Proc. 1999;74:758–763[Medline]
28. Finley JP, Human DG, Nanton MA, et al. Echocardiography by telephone—evaluation of pediatric heart disease at a distance. Am J Cardiol. 1989;63:1475–1477[CrossRef][Medline]

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