Category: Uncategorized

The Decade-Long Journey To NEJM Case 34-2010

Nov 22, 2010• 5

By BOB WACHTER, MD

The most popular article in last week’s New England Journal of Medicine did not tout the discovery of a novel gene, nor describe a cardiology clinical trial with a clever acronym as its title. Rather, it was the report of a case in which a surgeon at the Massachusetts General Hospital performed the wrong operation on a 65-year-old woman.

This was a breakthrough for the Journal – the first time in its storied 86-year history that the Case Records of the MGH published such a report. But it was not the first opportunity the NEJM had to publish such a piece… that occurred a decade earlier. The story of the path from then to now reflects the evolution of the patient safety movement. It’s a story I know well since it involved one of the lowest points in my professional life.

Before I share the back story, a word on last week’s article. David Ring, a prominent Harvard hand specialist, performed a carpal tunnel release on a patient who actually needed a trigger finger release – an entirely different operation. Showing great courage, Ring described his own error, with safety expert Gregg Meyer providing the color commentary.

As always, the pathophysiology of this misfire was a combination of active (i.e., somebody did something wrong) and latent (the system was a setup for failure) errors that jibed entirely with Jim Reason’s famous “Swiss cheese model” of “organizational accidents.”

THCB recommends…

Nov 22, 2010

The Congressional Shift and Health IT

Nov 22, 2010• 2

By JUSTIN BARNES

Following the shift to a Republican majority in the U.S. House of Representatives, the pre- and post-election focus of GOP leaders on repealing all or parts of the Patient Protection and Affordable Care Act (PPACA) have led to much discussion and media attention on whether the few true health IT aspects of the Act are in jeopardy, and has even extended speculation – and in some cases confusion – as to whether physician and hospital incentive funds within the government’s previous Meaningful Use initiative are also a target.

There are several foundational elements – and one major point of Meaningful Use funding – that should allay concerns for current and future funding for the adoption of certified electronic health records (EHRs).

Fundamentally it’s important to note that the Health Information Technology for Economic and Clinical Health (HITECH) Act, from which the Meaningful Use program and its funding originates within the American Recovery and Reinvestment Act (ARRA) of 2009, is an entirely different statute than PPACA.

Bipartisan support for the tenets and the spirit of HITECH dates back at least seven years, and it is also noteworthy that the Office of the National Coordinator for Health Information Technology (ONC), which administers Meaningful Use, was created by the Bush administration and a Republican Congress.

Politics aside though, the reason that Meaningful Use funds are secure is because they are drawn from the Medicare Trust Funds held by the U.S. Treasury, and are therefore not subject to annual Congressional budget appropriations or oversight.

In other words, the funding is grounded in law, and has inherent flexibility to encompass the number of ambulatory practices and hospitals seeking Meaningful Use incentives capture. The incentive payments are procured through the Centers for Medicare and Medicaid Services (CMS).

THCB recommends…

Nov 22, 2010

Announcing the Health 2.0 2011 Conference Schedule

Nov 19, 2010• 2

By THCB STAFF

We are pleased to announce our conference schedule for 2011. Our Spring Fling conference will be held in San Diego on March 21-22. This event will focus on three themes where there is a sense that Health 2.0 can make a real and lasting difference: containing health care costs; the future of research; and the triad of prevention, wellness, exercise and food. For our Fifth Annual Fall Health 2.0 Conference, we’ll be back in San Francisco on September 26-27.

Meaningful Meaningful Use

Nov 19, 2010• 14

By ROB LAMBERTS, MD

Quiz:

What does the term “meaningful use” mean?

a. Using something in a way that gives life purpose and leads to carefree days of glee.
b. It depends on your definition of the word “term.”
c. It is not mean. It is really nice.
d. A large number of rules created by the government to assess a practice’s use of electronic medical records so that they can spur adoption, give criteria for incentive rewards, and have physicians in a place where care can be measured.
e. Job security for those making money off of health IT.

The answer, of course is d and e.

Meaningful Use, in the eyes of many is seen as curse words, especially doctors.Continue reading…

Have We Found the Magic Acronym?

Nov 19, 2010• 13

By J.D. KLEINKE

Sometimes, reality just delivers – this morning in the form of some funny Google search results.

Aghast at the fluidity of my acronymic spew in an email exchange with a colleague (“ACOs can be MSOs instead of PHOs because Stark now safe-harbors EMRs for IPAs, so the PPMs and hospitals can share IT to TPA the risk piece, and…”), I decide to brush up on these new-fangled entities in the health reform law called “ACOs,” or Accountable Care Organizations.

In case you’re still stuck back on page 689 of the law, the ACO is This Year’s Model – the TLA (Three Letter Acronym) with Big Mo. An ACO is a contracting entity, codified in the health reform law, through which a group of physicians and a hospital or several hospitals work together to share in the financial risks and rewards associated with patient care. Sound eerily familiar? To me, the concept sounds like a bad movie I once saw – a really long and dreary drama with nothing close to a Hollywood ending. Or maybe it was a bad waking dream I had while dozing at a population risk management conference in 1998, thanks to a slight fever, two Sudafed, and half a bottle of Robitussin. Or maybe it was something I read that same year.

Hospital and physician integration has become ‘thinkable’ now, if only because physicians and hospitals finally recognize that they will sink or swim together, thrown as they have been into the same turbulent, unforgiving waters of a self-correcting marketplace. As a reaction to the cost crises of the 1980s and early 1990s, government and private purchasers – directly and through MCOs [managed care organizations] – have blamed both hospitals’ and physicians’ self-serving clinical behaviors, inefficient practices, and excess capacity as the main driver of their own health care spending woes. This is precisely why the purchasers turned the MCOs on them in the first place. This is why MCOs have been positioned as the enemy of both types of providers. And the enemy of my enemy is my friend, or so the thinking goes.

OMG, that was some big thinking! So the purpose of the 1998 vintage ACOs was to punch the MCOs (i.e., the 1998 vintage HMOs/EPOs/PPOs/POSPs/MOUSEs) in the nose. OK! But more on this little artifact in a moment.

The Fine Print

Nov 19, 2010• 11

By MARGALIT GUR-ARIE

Last week the American Medical Informatics Association (AMIA) released a position paper titled
“Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force.” The paper shines a bright light on the alleged contracting practices of EHR vendors and their notorious “hold harmless” clauses, which indemnify the EHR vendor from all liability due to software defects, including liability for personal injury and death of patients. What this means in plain English is that if a software “bug” or incompetency caused an adverse event, and if you (or your hospital) are faced with a malpractice suit, the EHR vendor cannot be named a co-defendant in that suit and you cannot turn around and bring suit against the vendor for failure to deliver a properly functioning product.

The AMIA paper also asserts the existence of contractual terms preventing users and purchasers from publicly reporting, or even mentioning, software defects, including ones that may endanger patient safety. The AMIA report goes on to challenge the ethics of both buyers and sellers engaging in such contracts, with an emphasis on the EHR vendors’ primary responsibility to shareholders and the bottom line in general.

As expected, the authors call for Government regulation of HIT products and processes and suggest that contracts should, of course, reflect a shared responsibility between vendors and customers and while public reporting should be allowed (or required) for certain types of software defects, users should be mindful of the vendor’s intellectual property. The interesting portion of the report is the rather novel recommendation for formal Ethics education amongst vendors and purchasers. Presumably, vendors and their customers need to be taught the difference between right and wrong and need to be informed that placing corporate profits (or personal comfort) ahead of patient safety is indeed wrong and therefore unethical. To borrow from the Windows 7 phone commercials, “Really?”

Augmenting My Reality

Nov 19, 2010

By ALEX EPSTEIN

When I first heard about Augmented Reality, I thought – this is really cool. Let me try and augment mine.

And I had a vision that included Scarlett Johannson (just kidding, sweetheart) and a home totally free of weekend honey-do’s and totally full of perfectly happy, compliant teenage children.

Hell, if I am going to augment reality… I might as well go for it.

How naive.

Imagine this – in the not too distant future a wearable device will display a seamless series of “helpful” tags on top of what you are actually seeing, so as to make your viewsing more effective.

Maybe you are part of surgical team involved in a complicated intervention, and your technology is superimposing real-time CT scans over your actual view of the operating field, hopefully improving outcomes. O0ps, that is happening now! The tags, and decision support, which will make things even mo betta will happen later.

Or say you are 18 and a Marine trying to repair a complicated hunk of your war machine (or maybe just a flat tire) in the desert or the jungle – special goggles will augment your reality with a layer of digital information that shows you how to fix your stuff in real time.

The Seduction of Primary Care

Nov 18, 2010• 83

By ROB LAMBERTS, MD

Hey there, big, smart, good-looking doctor….

Are you tired of being snubbed at all the parties? Are you tired of those mean old specialists having all of the fun?

I have something for you, something that will make you smile. Just come to me and see what I have for you. Embrace me and I will take away all of the bad things in your life. I am what you dream about. I am what you want. I am yours if you want me….

Seduce: verb [ trans. ]

attract (someone) to a belief or into a course of action that is inadvisable or foolhardy : they should not be seduced into thinking that their success ruled out the possibility of a relapse. See note at tempt .

(From the dictionary on my Mac, which I don’t know how to cite).

If you ever go to a professional meeting for doctors, make sure you spend time on the exhibition floor. What you see there will tell you a lot about our system and why it is in the shape it is. Besides physician recruiters, EMR vendors, and drug company booths, the biggest contingent of booths is that of the ancillary service vendors.

“You can code this as CPT-XYZ and get $200 per procedure!”

“This is billable to Medicare under ICD-ABC.DE and it reimburses $300. That’s a 90% margin for you!”

This is an especially strong temptation for primary care doctors, as our main source of income comes from the patient visit – something that is poorly reimbursed. Just draw a few lab tests, do a few scans, do this, do that, and your income goes up dramatically. The salespeople (usually attractive women, ironically) will give a passing nod to the medical rationale for these procedures, but the pitch is made on one thing: revenue.