Wednesday, September 14, 2011

Is meaningful use the right incentive to get physician's to use EMR's?

Before I took over one of the classes that now teach at the medical school, I asked students why the value of that class was so low.  One of the reasons they gave was that it was so hard to do well in the class, and there were so many other things to study, students only put in enough effort to pass.  In other words, incentives are only good if they are both valued and attainable.

As this related to Electronic Medical Records (EMR's), achieving meaningful use is not easy.  The technology for clinical decision support (a requirement) is not quite ready for prime time.  Nor is there an easy way to share parts of the EMR with patients.  In a study of almost 600 docs who had been using EMR's, most were confident that they would qualify for meaningful use and get bonuses for doing so.  However, the survey also found that the majority of these physicians would not meet some of the criteria.  Thus, though the financial incentive seems nice, the path to getting these incentive may be so unattainable that physicians won't waste the effort or expense.

More importantly, some of the "stuff" that's meaningful in meaningful use, may not have value for physicians. Policy makers that developed these criteria were understandably thinking on a population level (lowering blood sugar in a population of diabetics).  However, physicians are used to dealing with patients one on one.

A recent survey of EMR using physicians was done over at Software Advice regarding the advantages of using EMR's.  Granted 50 respondents may not accurately generalize to most physicians; however, some of the results are telling.  What do doctors like about EMR's? Greater accessibility of charts, easier to read notes, more accurate patient information,  and improved coordination of care by having the ability to share data.  As a user of EMR's for well over a decade, I would concur with these findings. EMR's are far from perfect, but based on these advantages, I could never go back to paper.  What  "benefits" of EMR's did doctors not see as readily? Improving preventative care, opportunity to participate in pay for performance, improving clinical decision making, and reducing errors/improving patient safety.  

Thus, under the current plan to increase EMR use by physicians, the financial incentives may be too hard to achieve and the purported benefits may not be easily perceived.  This combination does not bode well for the adoption of EMR's by most physicians.  Instead, policy makers might want to consider a different approach.  First, rather than create a financial carrot that will be too difficult to achieve for most, use that money to reduce barriers to adopting EMR's in the first place.  Second, instead of focusing on the benefits important to policy makers, focus on benefits that are important to physicians, such as making our work easier and more productive.  This is important because EMR vendors design their products on what they believe will meet their customer's needs.  The first EMR platforms focused on improvements in billing and coding to capture more revenue.  Now, vendors are focused on helping physicians achieve meaningful use.  If vendors focused on making a physicians work easier and more productive (and policy maker made it easier to adopt these tools), EMR adoption would be much greater than it is now.

Friday, September 2, 2011

Disappointing Results for Crestor

In my recent post All in for Crestor, I discussed how the SATURN study comparing Crestor to Lipitor was likely a make or break study for AstraZenca's cholesterol pill.  As mentioned, because Lipitor will soon go generic in November, AZ needed to give insurance companies a reason to pay for the more expensive branded pill, then the soon to be generic and cheaper version of Lipitor, which has been the number one selling drug in the country.

As reported in Pharmalot's post Disappointing Crestor Results For AstraZeneca (see the official AstraZeneca statement here ), the just released results of SATURN show that the 40mg dose of Crestor was numerically but not statistically significantly better and reducing plaque build up (as measured by % change) as the 80mg dose of Lipitor.  As secondary measure, plaque buildup as measured by volume was statistically significant, but since this was not the primary outcome of the study, it is likely enough for insurers to give Crestor a favorable status on their formulary lists.

Bottom Line: Crestor is a great drug.  It reduces LDL better than Lipitor.  We know that from outcome studies of all statins, that the lower the LDL with a statin, the more you decrease heart attacks and strokes.  In addition, despite it's potency, it has very good tolerability.  Certain patients that might need 80mg of Lipitor, might not be able to tolerate side effects at that high of a dose, and might end up doing better on 20mg or 40mg of Crestor.  That said, starting in 2012, unless AZ cuts the price on Crestor drastically, it may be a challenge to get the prescription approved for patients.