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TECHNOLOGY/QUALITY: The Digital Delivery System

Yesterday I was at Healthtech’s conference on The Digital Delivery System. Healthtech is a non-profit research consulting group which conducts research on information and medical technologies, and how their emergence and use will impact hospital systems. Healthtech is led by health care superstar Molly Coye, who’s been in both the public and private sector, and is one of the authors of the recent IOM reports on patient safety and quality. The meeting attendees are IT folk from large hospitals systems that care about how they’re going to use technology to change their clinical processes, while not being shot by their medical and financial staff in the process.

The key issue being discussed at the conference is how do you get standardized clinical procedures used uniformly across a system. IT clearly helps and is a driver, but non-IT solutions work too. The keynote speech was by Brent James, from Intermountain Healthcare (IHC) in Utah, who have long been EMR pioneers. Most of the rest of this is my take on James’ speech. Of course apologies are mine if I misconstrued information, but there was much good stuff in it. James introduced his talk with three quick stories.

a) a color coded discharge tool for severity assessment at Primary Childrens hospital was developed by the residents and was taken up by the management. During a viral outbreak that happens every so often in Utah, they had been so swamped that they had to close the OR for 18 days. When the next outbreak hit, using the discharge tool they were able to reduce ALOS by one day and the OR was only shut for 1 day.

b) Traditionally a general internist plus 2 assistants can manage 600 patients on Coumadin/Warfarin. With a virtual lab seeing the results of patient measurements taken across the Intermountain system, one 50% time Nurse Practitioner plus one assistant can now monitor and look after 1400 patients.

c) James’ dad enters info on an IHC website that monitors his CHF, and monitors his care every day. If any of his measures go downhill, a nurse calls and schedules follow up. He is doing well and is healthier than he’s been for a long time.

James introduced the story of how well medical care has done in improving life and health. Then James got into the nitty gritty of how poorly we’ve done to move that scientific marvel over the context of all care provided to a population. He displayed some grimly amusing charts that showed that Beta blockers were used on discharge for acute MI patients 48% of the time by major teaching hospitals (and only in the 30% range for community hospitals). And this had direct results on mortality 2 years later–mortality was higher in the community hospitals. But more to the point, as he said: "We get it right 50-55% of the time and we achieve miracles. What would happen if we got it right 70% of the time?".

Medicine is much more complex now than it used to be. Back in the 19th century there were 6 active medications; by 1970 60-100 medications. Now as a general internist you should know 600 drugs.

So can you make this complexity better? Traditionally medical practice says you can’t– the mistakes and missing the best care protocols are just the price you pay for complexity. But IHC showed that with a simple check sheet on discharge that the nurse fills out, IHC got beta blocker use from 56% up to the high 90%s! So it is possible to do better than the 55% appropriate care that RAND showed we currently expect! In the IHC system this saved 331 lives per year for CHF and reduced hospitalization rate by 551 admissions. Brent believes that closing that gap represents the future of medicine. But he didn’t want to talk about who gets the money!

Another area IHC has used IT is in avoiding ADEs (medication errors). "Voluntary" incidence reporting reveals less than 1% of actual ADEs. At IHC ADEs went from 15 per year in the 1980s (detected by incidence reporting) to 580 in 1991 (when they started counting using an IT system) but came down to 280 by 1999. At IHC they found that 66% of these ADEs were preventable–hence the reduction. And all this saves money, on average $2,400 per ADE. James thinks their error rate is still too high. But nonetheless he says if you are sick, you should come to IHC in Utah because you are going to have significantly lower chance of getting a complication!

Diabetes care is another area of concentration. (IHC is in top decile for HbA1c control in HEDIS/NCQA). Every quarter their docs get a report card on diabetic care, and IHC gives them a notification of any patient off the protocol–before the patient comes in. This can also work off the EMR, and any time a diabetic comes in a new chart front is printed out with a whole worksheet so that the patient is checked in their visit for all that’s needed according to the protocols. This measurement system is backed up with a home glucometer and an interactive website for the patient. IHC has seen care rates again improve to make them better than the top decile.

Overall the IHC experience, which has been well known within the medical quality and EBM circles needs to still get more publicity. As another speaker said later in the day, no other industry would get away with this level of safety violations. But perhaps if consumers really knew not only that appropriate care was provided just 55% of the time, but there is a real live American example of a place getting it right more than 90% of the time, the reaction would force the system into much faster change.

More on my sense of where the IT folk are on creating the infrastructure for that change tomorrow.

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