I haven’t made it a secret in these posts that I’m a big fan of electronic health records (EHRs).  I think they improve patient care, and I think that paper medical charts will eventually go the way of the vinyl LP.  (For those of you born after 1980, I’m referring to an archaic music recording medium.  Yes, even more archaic than the CD.)

I’ve also written before about the very slow rate of adoption of EHRs by physicians.  Well, it turns out hospitals are no better.  A study in this week’s New England Journal of Medicine surveyed American hospitals for their use of EHRs.  The results were underwhelming.  Fewer than 2% of U.S. hospitals have electronic records in all clinical units.  Another 7.6% of hospitals have EHR in some units and not in others.

The barrier most frequently cited by hospitals for EHR adoption was, not surprisingly, the same barrier physicians cited: cost.  EHRs cost money, and in a marketplace which reimburses for quantity, not quality, who is going to make a major investment in better patient care?  Insurance companies pay a fixed price for each service provided, whether the outcome is fantastic or marginal, whether the patient is delighted or frustrated.  The financial incentive in such a market is to increase quantity as much as possible and to provide quality that is only good enough to avoid lawsuits.

Policy wonks and politicians (in both the current and previous administrations) hope to solve this problem by government subsidies for EHR adoption.  An article in yesterday’s Wall Street Journal cites a Congressional Budget Office estimate that over $20 billion will be spent by the federal government on health-information technology between 2011 and 2015.  EHR companies are naturally delighted as it will increase their revenue enormously.  Most physicians and hospitals won’t object either, since they will be handed a valuable tool at taxpayer expense.

I think patients (not to mention taxpayers) should be more skeptical.  First of all, the price of EHRs will skyrocket if they are subsidized.  (See the price of healthcare after Medicare was enacted.)  Second, there is little reason to believe that those who are handed a “free” EHR will use it as productively as those who invested their own resources to buy it.  After all, those who see the most value in it have already voted with their dollars; those who see the least value in it will require the largest subsidy to buy in.  So the cost will inevitably be greater than expected and the benefits to patients much less.

CDs replaced LPs because music fans were willing to pay a few more dollars for better music.  EHRs will inevitably replace paper charts.  But it will happen when patients (not insurance companies or government) are allowed to pay a little more for better care.

Learn more:

Wall Street Journal article: U.S. Hospitals Slow to Adopt E-Records

New England Journal of Medicine study: Use of Electronic Health Records in U.S. Hospitals

My previous post on EHRs: Only 4% of American Physicians Have Electronic Health Records

About 20 years ago a blood test called prostate specific antigen (PSA) was developed with the hope that it would help in the diagnosis of prostate cancer.  Since then, countless healthy men have been tested for prostate cancer with a PSA and a digital rectal exam despite the fact that there has never been convincing evidence that diagnosing prostate cancer saves lives.

The reason for the controversy about prostate cancer screening is that prostate cancer is a very slowly growing cancer which usually takes a decade or longer to be life-threatening.  Prostate cancer also occurs in older men.  So many cases of prostate cancer never cause symptoms and do not shorten lifespan.  The treatments for prostate cancer, on the other hand, can involve serious and permanent side effects, including urinary incontinence and erectile dysfunction.

The most important question about prostate cancer screening has always been does it save any lives?  And if it does, is it worth putting men through potentially harmful treatment now for the possibility that we’re saving their lives 10 years from now?

Two studies released this week in the New England Journal of Medicine unfortunately don’t help clear the fog, and have generated much media attention.  (See links below.)  The first study was a randomized trial in the US which showed that prostate cancer screening did not prevent any deaths from prostate cancer.  This study, however, had some serious methodological flaws.

The second study randomized over 100,000 men in Europe into two groups: one which received periodic prostate cancer screening, and one which did not.  The results showed a tiny mortality advantage 9 years after being screened.  There was one life saved for every 1410 men screened for prostate cancer and for every 48 men treated for prostate cancer.  That’s not a very compelling benefit.  It means that 47 men are harmed by prostate cancer treatment for every life saved and that screening an individual has a smaller than 0.1% chance of helping him.  Given this tiny benefit, it’s difficult to say if more harm was done than good.

The US Preventive Services Task Force states that the evidence is insufficient to recommend for or against screening for prostate cancer in men age 50 to 75.  It recommends against screening men older than 75.  For men between 50 and 75 that still means a discussion with their physicians about the possible risks and uncertain benefits of screening, and then making a personal decision without much scientific guidance.

Learn more:

NY Times editorial:  The Prostate Cancer Muddle

LA Times article:  Studies cast doubt on prostate cancer screenings

The US Preventive Services Task Force recommendations regarding prostate cancer screening

The two New England Journal of Medicine articles: Mortality Results from a Randomized Prostate-Cancer Screening Trial and Screening and Prostate-Cancer Mortality in a Randomized European Study

Three weeks ago I wrote about the difficulty of quitting smoking.  This week I’m writing about an even harder habit to break – problem drinking.

Our understanding of alcohol use and abuse is evolving.  Alcoholism or alcohol abuse is defined as continued alcohol drinking despite negative consequences, whether those negative consequences are to one’s work, relationships or health.  Alcohol abuse happens to different people at different quantities of drinking, so the amount of drinking was never the focus.  It was the fact that drinking continued despite bad consequences.

A valuable article in the Wall Street Journal this week reviews the change in thinking about alcohol abuse and points to a useful new website for patients from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).  We now know that even without adverse consequences, people who drink more are at much higher risk of progressing to alcoholism that those who don’t.

The NIAAA definition of low-risk drinking for men is 14 or fewer drinks per week and 4 or fewer drinks on any day.  For women it’s 7 or fewer drinks per week and 3 or fewer drinks on any day.  For men and women over 65, low-risk drinking is defined as no more than 1 drink daily.  For other groups of people, including patients taking medications that interact with alcohol, pregnant women, and patients with liver disease or heart disease, complete abstinence is recommended.  Only about 2% of low-risk drinkers go on to alcohol abuse.  Those who exceed either the daily or weekly definitions of low-risk drinking have a 20% chance of developing alcohol abuse.  And 50% of those who exceed both the daily and weekly limits develop alcoholism.

If you’re curious about whether or not you should drink less, I urge you to follow the link below to the NIAAA website and enter your drinking pattern.  It’s completely anonymous, so it’s a safe way to see how you compare with the general public and what risk your drinking pattern poses.  You’re the only one who can decide whether or not to make a change.  The NIAAA website is just an educational place to start.

Learn more:

Website from the National Institute on Alcohol Abuse and Alcoholism:  Rethinking Drinking

Wall Street Journal article:  To Your Health: New Web Site Helps Predict Alcohol Problems

I don’t know about you, but whenever I think of March, the first thought that springs to mind is National Colorectal Cancer Awareness Month.

Patients frequently ask me to be tested for whichever cancer they are particularly anxious about.  “Is there a test to make sure I don’t have early ovarian cancer?”  “Pancreatic cancer?”  “Lymphoma?”  I have to explain that for healthy people without any symptoms, there is no test that has been proven to find these malignancies early or save lives by finding these diseases.  In fact, for most cancers we don’t have accurate screening tests, and for some cancers it’s not even clear that finding the cancer early saves lives.

Colon cancer is a major exception.  There is very solid evidence that testing for colon cancer in healthy people with no symptoms catches colon cancer early and saves lives.  That’s why I bug my patients relentlessly about having a screening colonoscopy.

Who should be screened?  Everyone between the ages of 50 and 75, but those with a family history of colon cancer may benefit from earlier screening depending on the details.  And particularly healthy people aged 75 to 85 may benefit from screening as well.  For more details, I encourage you to click on the link to the US Preventive Services Task Force recommendations below.

Screening is usually done by a colonoscopy, and if the colonoscopy is completely normal, it need not be repeated for 10 years.  Though lots of my patients dread their first colonoscopy, they invariably tell me afterwards that it wasn’t that bad.  Anyway, a procedure once a decade in return for a practical guarantee not to die of the second leading cancer killer in the US is a pretty good deal.

I think what National Colorectal Cancer Awareness Month needs is a snappy slogan, like “A Colonoscopy a Decade Keeps the Oncologist Away” or maybe “The Light at the End of the Tunnel is a Colonoscope”.

Learn more:

CDC Features:  March is National Colorectal Cancer Awareness Month

US Preventive Services Task Force recommendations on colorectal cancer screening

US News article:  Colon Screening: 5 Things You Need to Know