Medical Device Daily Washington Editor

WASHINGTON – The assertion that Americans spend a lot of time paddling around in a sea of information about diseases and prevention would excite no dissent from the man or woman on the street, but medical societies often seem oblivious to healthcare “infoglut.”

Still, even when a group of physicians and policy types convene to discuss how to promote preventive care with that understanding, there seems to be little consensus on what to do about it other than to make one’s case either more forcefully or more artfully. Such was the case at the second day of the two-day symposium on screening for colorectal cancers (CRC), sponsored by the Institute of Medicine (Washington).

In one of the day’s sessions, Carrie Klabunde, PhD, an epidemiologist with the National Cancer Institute, gave an overview of practice models for delivering colorectal cancer (CRC) screening and their cost implications. Klabunde said “cost data are hard to come by, especially in the primary care practice setting.” This is partly due to the fact that “healthcare is largely decentralized in the U.S.,” she said, but also because healthcare information technology has made only modest inroads in the clinical practice setting.

In a survey conducted by several federal agencies to explore the question, physicians were divided into two groups. One group responded to a survey that addressed breast and cervical cancer screening and the other group CRC screening. Both arms of this survey also looked into the use of electronic medical records and whether electronic and manual reminder systems were in use.

“About 26% [of the 1,266 respondents] were in solo practice,” Klabunde said in reference to the CRC group, and another 41% were in physician groups of five MDs or less. The group was largely white and male, and those under the age of 40 made up only one in five of respondents.

Klabunde said that the doctors’ responses indicated that “[o]nly about half the eligible population is being screened,” but she said that doctors nonetheless claim they recommend it to all their eligible patients (current guidelines call for a CRC screen at the age of 50 and each decade thereafter). “Part of the explanation” for the seeming disparity “is the use of electronic office systems,” Klabunde said, noting that about 56% of the practices “were still using paper charts.”

Physician practices do not necessarily have to rely on computerized reminder systems to prompt their patients to get their CRC screens, but few of the options are cheap. Klabunde asked rhetorically, “[I]f a practice wanted to improve [screening rates] by hiring a physician’s assistant (PA), what would that cost?” The average annual salary for PAs is $75,000, and after paying the benefits, the total cost approaches $100,000 per year.

As for electronic medical record (EMR) systems, she said the up-front costs are about $24,000 per physician in an integrated healthcare system and almost $44,000 per physician for a small practice. Add in maintenance costs, and “you can see that this can get pretty substantial,” Klabunde said. “In a five-physician practice, it can cost $200,000.”

As the data show, “office systems can be quite expensive,” Klabunde said, adding that although “EMRs are a promising component,” barriers include interoperability, especially when a practice “crosses organizational boundaries.”

In the following presentation, Richard Wender, MD, chair of the department of family practice at Thomas Jefferson University (Philadelphia), discussed “the ecology of medical care.” The typical practice, he said, consist of between two and five doctors, and they and their staffers are immersed in “a climate permeated with stress and overwork.”

Wender said also that most such practices “work on the margins of financial viability,” leaving them with little time or other resources to take a birds-eye view of their operations.

“Primary care clinicians virtually all recommend screening,” Wender said, but few manage to get each of their eligible patients to go along. Some doctors are concerned about whether the patient can afford the procedure and whether the doctor will be reimbursed. “Some of them clearly perceive a financial disincentive” to promote screening, he said, due to the notion that reimbursement either marginally covers the cost or does not at all.

“Prevention is generally perceived as a distraction from those things that generate a bill, which comes down to the number of visits,” Wender said. The greater complexity of determining which of the available tests is the most appropriate is also a barrier, which Wender contrasted with the relatively simple blood test used to detect prostate-specific antigen (PSA). PSA tests, he said, “occur at a remarkably high rate ... despite a less compelling evidence base” compared to CRC screening.

“Greater investment in [information] technology has not to date been associated” with higher rates of screening, Wender said. As for getting patient on board, he said that data indicate they “prefer personal contact methods as opposed to technological contact methods” for reminders of the need for CRC screening.

In the discussion that followed, panel moderator Thomas Kean observed that message clutter may be part of the reason the message about CRC screening seems to fall on deaf ears at times. “People are buried in messages” on the subject of healthcare in general and diseases in specific, Kean said.

“We’re out there, so are the diabetes people and so is everyone else. The public is very confused right now,” said Kean, who is executive director of the anti-cancer coalition C-Change (Washington). He said “there is a segment of the population that is not too difficult to capture” with further efforts, so proponents of CRC screening should go after them first, but “there also needs to be some national program to cover the uninsured and the underinsured. It needs to be more than a token effort.”

Kean also said that despite understandable calls for nationalized healthcare, more attention should be paid in the short run “to incremental change as opposed to waiting for the Big Bang.”