EMRs, Checklists and Meeting Atul

Recently, I got to shake hands with and also have lunch with doctor-writer extraordinaire Atul Gawande! He was nearly everything I had made him out to be. He wore a snappy blue blazer, a jumble of ID tags, and round specs befitting a prominent Harvard academic doc … only he wore them in a manner that suggested a man of action. Am I gushing? Sorry. I’ll stop … except to say that he had the chicken salad on white, which sat largely untouched as he drove through the conversation.

One of the greatest storytellers in the history of health care, Atul has discovered something very important about the way we deliver complex procedures … a series of checklists that bring down costs and improve outcomes … and yet adoption of his findings is incredibly low! He is seriously considering raising money to fund—NOT to continue his research and writing—but to literally fund a team of Maoist-like activists to cajole the ranks of docs and hospitals into adopting these bloody checklists!! These checklists are real bluebirds. Nobody loses their job from the adoption of these things. Except for a few embarrassing ‘re-operations to fix terrible mistakes, nobody loses any money either. So what gives?

Atul told me the story of penicillin adoption … I was stunned at how long it took for this miracle drug to be mainstreamed. I remember from my OB-GYN days the number of docs who were still doing continuous fetal monitoring during labor, twenty years and five studies after it was shown to be counter-indicated … and episiotomies, and circumcisions (ouch)!

How frustrating.

These are good people. I have met literally tens of thousands of docs and can count the truly questionable people on one hand. So what is it?

There is no market mechanism for the solution. That’s what.

If a payer came to me and gave me Atul’s checklist and said they’d pay even 5% more for a surgery done according to his checklist, I’d build it into an EMR and flick it in within a week! It’s a no-brainer for me and it’s good money for the doc! Ya know what that would be an example of? That would be MEANINGFUL use of an EMR.

God Bless you, Atul. I’m in for a donation … but not for the Maoists. You go find the truth and we’ll go make a market for it.

PS … Atul signed my copy of his book!

Jonathan Bush co-founded athenahealth, a leading provider of internet-based business services to physicians since 1997. Prior to joining athenahealth, he served as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant with Booz Allen & Hamilton. He obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School.

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12 replies »

  1. Thank you very much for posting such a nice information Atul…Electronic medical record is very useful for better hospital management…it works really very well…!

  2. This post makes me angry. Docs are going the way of the airlines – expecting to be paid an extra fee for every little thing (Spirit is now charging for carry-on luggage). And then the latest reports saying physician’s incomes went UP last year. One should never be paid extra for merely doing one’s job right.
    Thanks, Dr. Bush, for advocating the further commoditization of medicine – you get the result you wish for.
    As Justine points out:
    “The checklist is a reminder of what should have been taught in medical school and in residency training. 25 years ago, I saw impeccable attention to detail of procedure and sterility without checklists.”
    Add to this, doing a physical examination on patients, bothering to obtain their past medical history before you see them, bothering to call and then write a consultation report and send it to the primary if you were a specialist, on and on – this has all dropped by the wayside in the past 20 years.
    And Dr. Wei; I challenge you to provide references for the “many” studies failing to show improved outcomes (the presence or absence of computers is irrelevant to implementing the checklists). Doctors on this blog love to sling assertions around without supporting references – another thing which would not have been tolerated 20 years ago.

  3. The checklist is a reminder of what should have been taught in medical school and in residency training. 25 years ago, I saw impeccable attention to detail of procedure and sterility without checklists.
    It became abhorrent to see the erosion of these principles as medical care became hurried as a volume business, the perpetrators being hospital administrators at the behest of the government payment gig of DRG, founded at the Johns Hopkins Hospital.
    No one had time to do the right thing while making money for the hospital CEOs, most of whom are compensated in 7 figures.
    I will never forget the case who was sent to that program for heart valve disease and was hurriedly sent back without a diagnosis, but with the said valve infected after invasive evauation.

  4. I think it is a great Idea to use a Check List.Doctors have expressed interest in this check list for themselves but have little interest in its implementation for others.
    I don’t know if it is arrogance or lazyness that is the reason most hospitals choose to ignore the obvious.
    However,It is blantantly obvious that the medical Profession is largly cutting corners regarding Patient Safety and doing as little as possible to stop the Spread of Hospital Acquired Staph Infections.
    So what is the answer? Profit and Greed!! If these are the only reasons someone chooses to go into this industry. It is pretty sick and perverted.

  5. In Washington State there is a UW provider driven “checklist” initiative that is being implemented at all of our hospitals called SCOAP. .http://www.scoap.org/checklist/ indcludes video and handouts for anyone else who wants to implement it.
    SCOAP has produced a safety and quality checklist for the OR which is rolling out in all hospitals in Washington State. The checklist is used at the start of surgery as part of an extended “time out” and after surgery as part of a debriefing. The SCOAP OR Surgical Checklist, which goes beyond the JCAHO “time out” concept, guarantees that vital steps to a successful procedure are carried out and reinforces a culture of patient safety.
    In January 2009, a coalition of healthcare stakeholders supported the initiative’s goal of having a SCOAP checklist in every OR at every hospital in Washington State by the end of the year. By March 2010, ALL Washington state hospitals (plus some of the free-standing surgery centers) were in the process of implementing the use of the checklist.
    Let me know if you need assistance implementing it – I was the only consumer on the State Hospital Association – Patient Safety Committee. 😉

  6. Great case there, Peter. Screw up here.
    Read with interest.
    Computerization of organ and blood typing was commonplace at that time. One company’s product was recalled and its conduct was chastised by the FDA a few years before this horrific part computer part human error. Humans always took the blame back then, but now, we know, many of the devices are poorly usable and electronic communications are obfuscated with jabberwock. Until these devices are treated as the products of pharma are treated, ie, methodologically studied and approved for safety and efficacy, doctors will need checklists to be check that the care from the computer is delivered to the right patient at the right time. Cause it often is not the case in the wired hospitals as one of the links to the HufPo demonstrated.

  7. “Paul, did it make any difference in the overall outcomes of all cases at your hospital? Many reports are out there that show no reduction in costs and no improvement in outcomes.”
    Would it have made a difference here?
    Why is it (some) docs don’t want to be reduced to mere checklist checkers, but astronauts accept it as a way to preserve their lives and the success of the mission?
    Dr. Wei, do you want pilots to perform checklists in the plane you’re riding in?

  8. This is a mischaracterization of the field of patient safety. I’m not sure about the success Dr. Gawander has had, but Peter Pronovost’s team, who established their safety systems in Michigan and then took it on the road to Johns Hopkins, are well into large pilot studies in several states regarding similar checklists techniques (these being to reduce central line and other bloodstream infections). The techniques have been very successful in Michigan and Johns Hopkins, but are encountering difficulties scaling up due to the lack of trained “evangelists” for the approach (that is, its not enough to have a checklists, you need cultural buy-in from the institution).
    I understand Dr. Gawande’s checklists are for different procedures, but to write a post lamenting the lack of adoption of patient safety culture without mentioning the VERY VERY large-scale work others are doing right now, when your own blog covered it a few days ago, is just sloppy.
    And, there is a market solution. The new health care bill does not pay hospitals when they have to readmit patients for bloodstream infections. Voila.

  9. Many good things can come from computerization of checklists and computerized control of medical care. Funny, Paul should write after the HP computerization giant’s CEO was removed for improprieties, and several days after the scholars at the BIDMC published in the Archives how they can control what medications and their doses that doctors order for the elderly.
    Of course it can be done. Paul, did it make any difference in the overall outcomes of all cases at your hospital? Many reports are out there that show no reduction in costs and no improvement in outcomes.
    Have the checklists reduced morbidity and mortality at your hospital or any other hospital not part of the Pronovost experiments? Atula the god.

  10. Jonathan,
    I agree with Margalit. The idea of paying people extra to follow procedures and principles of process improvement just doesn’t ring true. It also is not necessary. At our hospital and others, these approaches have become more and more mainstream. They occur because of clinical leadership and because we are transparent with regard to clinical outcomes. Here’s an example: http://runningahospital.blogspot.com/2010/01/progress-in-icus.html

  11. … and this is why health care costs are exploding….
    Does American Airlines pay more for pilots to use checklists?
    Does Toyota pay more for its workers to follow company standard procedures?
    Only in health care we have to pay 5% more for folks to wash their hands…. or we get to be classified as Maoists.