Saturday, May 24, 2008

Google Health

This week, Google rolled out its new electronic medical record (EMR) function, Google Health. I am not particularly impressed. Don't get me wrong, I love Google, in fact I can't imagine my personal or professional life without it (I consult with my colleague Dr. Google, MD, frequently). And, it's not that I distrust health information technology, on the contrary, I am a convert to the new frontier of the EMR. Kaiser Permanente's EPIC system makes my clinical care better and more efficient on a daily basis. The available research supports my personal experience: EMRs are estimated to improve efficiency by 6% a year and (from a recent Kaiser study)* significantly improve coordination of care between multiple providers. Fewer redundant laboratory and xray tests are ordered, medication errors are reduced and waste is lessened by reams and reams. The end result is not only better patient care, but also a significant cost savings - an estimated $5-$10 million per year at one prominent academic center (Brigham and Women’s Hospital in Boston).

The problem with Google Health, as I see it, is that at least in its infancy it relies on patient driven (rather than provider-driven) coordination of medical records. One of the four bulleted selling-points on the Google Health welcome page urges patients to "Keep your doctors up-to-date about your health." As I am sure most providers would agree, this is a fabulous idea. Working in the ED, I am tremendously appreciative of patients who bring and show me an updated list of medications they are taking. Nonetheless, I find that even the most fastidious of patients hand me lists that contain duplications, miss-spellings or omissions. This is understandable; just as I excuse myself for not recalling which index funds I hold in my retirement account, I don't expect patients without medical backgrounds to keep completely accurate records of a laundry list of medications. So, the idea that patients be the caretakers of their own medical information, while laudable, will turn out to be unreliable. With Google Health, patients enter only the medical information they want to, and although Google promises to safeguard personal health information, there are sure to be privacy concerns. A better model, I think, (and I am clearly biased here) is an integrated health system with a universal IT system. In this (provider-driven) system, patients can review all of their medical information and are encouraged to alert their doctors to changes or inaccuracies. Ideally, this sort of system would offer incentives to patients who are actively involved with their medical record and help to keep them up-to-date. This sort of EMR hold tremendous potential for providers and patients. Google Health, on the other hand, will appeal to a small segment of tech-savvy and health-conscious patients and probably make money doing so. This result offers little in the way of improving our national health, and if anything may add to the divide between the have and have-not's. It's probably too early to pass judgement, but I don't anticipate becoming part of the Google Health community.

*Graetz et al. Care coordination across clinicians and health information technology: connecting the medical home with the rest of the village.

Answers from the previous post's trivia, with accompanying links found through my good friend Google:

A) A girl born with two faces (TRUE

B) A parasite twin (a fetus growing inside of another fetus) (TRUE)

C) A girl born with a cyclops eye (TRUE)

D) A boy with a true human tail (TRUE)

E) A true hermaphrodite with both ovarian and testicular tissue (TRUE)

Friday, May 2, 2008

It's in the liver, baby

For those of you who think that your liver's only function is to detoxify your body after a night at the saloon, check out this story:

In May 2003, a South African woman carried a healthy baby girl to term on and in her liver. When my wife Angela brought home this tale of miraculous reproduction from her anatomy class a few weeks ago, I was dubious. A healthy baby, growing in the liver? That sounded impossible. How did it get there? How could it survive? It turned out, however, that as usual my wife was right. Apparently this baby, back when it was nothing more than a fertilized egg, fell off the path to the uterus, floated through the abdomen, and implanted on the liver. It turns out that the path from ovary to uterus via the fallopian tube is not as tightly sealed as you might expect, and occasionally eggs lose their way. Normally, these eggs, without the rich blood supply of the uterus, wither and get reabsorbed. But, in this situation, and in a dozen or so other previously reported cases, the egg found a happy, well-vascularized (albeit alternative) home. The resulting pregnancy was extremely high-risk; without the protection of the muscular walls of the uterus, even minor trauma could have threatened the fetus. And, if the fetus or placenta had obstructed the blood or bile vessels of the liver, the mother's life would have been in danger. But, in this case, both mom and baby were fortunate; there were no serious complications, and the anomalous location of the baby was not discovered until a c-section was performed during labor. In a country with routine prenatal care, this miraculous liver pregnancy would almost certainly have suffered a different fate. Consider, a recent case report in the journal Obstetrics and Gynecology describing the "Diagnosis and Management of Hepatic Ectopic Pregnancy." (Obstetrics & Gynecology 2007;109:544-546) In this case, a woman with abdominal pain, a positive pregnancy test and an empty uterus on Ultrasound, went through a battery of tests and procedures until a MRI identified an 11-week ectopic pregnancy with fetal cardiac activity located in the maternal liver. This pregnancy, due to it's high risk nature, was successfully terminated with fetal injections of methotrexate and potassium chloride (under ultrasound guidance) and subsequent maternal intramuscular injection of methotrexate. I am sure there are some right-to-lifers out there who would argue that since this mother's life was not in imminent danger, the fetus should have been protected. The healthy liver baby from South Africa does give this argument some semblance of credence. Western medicine is efficient and saves lives, but its application does preclude some of nature's miraculous anomalies.

Medical Anomaly Trivia:
Which of the following are actual, reported, medical anomalies;

A) A girl born with two faces
B) A parasite twin (a fetus growing inside of another fetus)
C) A girl born with a cyclops eye
D) A boy with a true human tail
E) A true hermaphrodite with both ovarian and testicular tissue

Answers next week...