Category: Uncategorized

Computer Error or Patient-Centered Care?

Sep 8, 2010• 1

By HERBERT MATHEWSON, MD

The saga continues, but morphs from a discussion of computer error into patient-centered care (1).

In my last two posts I tell my story of trying to speed up a six-hour infusion of intravenous medication by correcting a “computer error”; a “failure to update reference information” in the computer available to the nurses. My first clue was the discrepancy between the medication’s package insert and the computer information. Discussion with the infusion nurses and a call to the Hospital’s chief pharmacist caused a review of the computer info, the package insert, and the hospital’s Pharmacy and Therapeutics Committee minutes.

The package insert stated that “after the initial 30 minutes without a side-effect the infusion rate could be gradually increased to the maximum rate.” The infusion nurses’ interpretation of “gradually” was a infusion rate step-up every 30 minutes resulting in a six-hour infusion. My preference was for a two hour infusion. I looked diligently, and in vain, for the manufacturer’s definition of “gradually”, so I called its 800 number . A very knowledgeable and accommodating RN in the Professional Services Department ( I identified myself as a physician) explained that they did not define “gradually” because they wished “not to be too proscribing, realized that individual patients varied, and respected each facility’s responsibility to set their own protocols.” It sounded like pretty good risk management (avoidance of increased liability) to me. She went on to say that many facilities had used a rate step-up schedule of 15 minutes rather than 30 minutes without increased side-effects and offered to send us the articles describing this.

Going to a step-up rate 0f every 15 minutes rather than 30 minutes would result in a four and a half hour infusion instead of a six hour one; still longer than my initially hoped-for two hours. Could the change in duration be labeled a triumph of “patient-centered care”? If so, was it worth all the time and effort?Continue reading…

Do Patients Want to Punish?

Sep 7, 2010• 2

Levy By PAUL LEVY

There is a great debate set forth in the IHI’s Open School discussion of the wrong-side surgery case that occurred at our hospital a few years ago. (I have written about this below, but there are some new postings.)

Kimberlee Ziga writes: I, as an RN working in an ICU, have also made mistakes. Thank God they have not been life threatening but nonetheless, they were mistakes. I was educated thoroughly and proven to be competent with testing. When I made that mistake, I was written up. I totally understood why. I am a licensed professional who is competent at her job, and that calls for accountability and responsibility. I believe all the medical staff involved should have been held accountable and disciplined accordingly. If that was my family member, I would have been irate for what they had to go through.

In contrast, Jessie Moon says: Paul Levy . . . made it out like it was a serious situation, but one that could happen to any surgery team. He* did not punish any one person, but instead he took care of the situation by asking, “how can we lower the chances of this ever happening again”, which makes the person and the family that this happened to feel better (or so I would assume), the public, as well as the workers in this hospital.

There are two parts to this question. What is the most effective way to reduce the likelihood of a similar event happening in the future? I have addressed this topic fully below. At heart, the answer goes to the definition of the “just culture” that has been adopted by a hospital.

HIT Trends Summary for August 2010

Sep 6, 2010• 5

By MICHAEL LAKE

This is a summary of the HIT Trends Report for August 2010.

You can get the current issue or subscribe here

Large insurers make HIT commitments. This month’s trends are dominated by national health plans revealing more about their HIT strategies. Dr. Blumenthal called HIT a “team sport,” when asking for private industry support for meaningful use. National insurers responded. Humana announced that it will collaborate with athenahealth in 100 physician practices and pay for 85% of the costs of its EHR. It will also pay a 20% bonus for hitting outcomes targets. Ingenix, part of UnitedHealthcare Group, reported it is buying Axolotl, a leader in health information exchange. Aetna announced a partnership between its ActiveHealth care management solution and IBM who will provide clinical decision support to providers in large groups using cloud computing. And WellPoint told the WSJ that it is investing hundreds of millions of dollars to finance the HIT infrastructure for rural providers. In response to a consumer advocate raising questions about an inherent conflict when payers support provider HIT efforts, health plans responded by insisting their focus is on improving patient outcomes which will lower costs. Payer investments in provider HIT will be supported by its inclusion as a medical expense when insurers calculate medical loss ratios. The National Association of Insurance Commissioners approved its inclusion in new MLR blanks.

Independent Advisors Prove Independent

Sep 3, 2010• 10

By MERRILL GOOZNER
Journalist-turned-stock-analyst Ramsey Baghdadi of Concept Capital, who formerly wrote for the RPM Report, tells TheStreet.com that Food and Drug Administration Advisory Committee recommendations are down to 52 percent “yes” votes this year, “the worst year since 2007.” He compares that unfavorably to 2009 and 2008 when the advisors gave positive nods 75 and 80 percent of the time.

Reasons for the tougher regulatory environment, according to Baghdadi? “First, the FDA is bringing more drugs in front of advisory panels due to changes in FDA law that require most new drugs to be reviewed by outside experts,” the article notes. “Second, stricter conflict of interest rules implemented by FDA (in the wake of the 2007 reform law) have made it more difficult for the agency to recruit experienced panel members.”

If inexperienced members without conflicts of interest are more prone to voting no, how does that explain 2007, when the current rules weren’t in place and there were still 50 percent “no” votes?Continue reading…

Beyond Meaningful Use: Three Five-Year Trends in the Uses of Patient Health Data and Clinical IT

Sep 2, 2010• 17

By DAVID C. KIBBE, MD and BRIAN KLEPPER, PhD

Finally, we have a Final Rule on the Medicare and Medicaid EHR incentive programs. The rules and criteria are simpler and more flexible, and the measures easier to compute. But they are still an “all or nothing” proposition for physicians, who will have to meet all of the objectives and measures to receive any incentive payment. Doctors who get three-quarters of the way there won’t receive a dime. And a lot of uncertainty remains about dependent processes that CMS and ONC must quickly put in place, like accreditation of “testing and certifying bodies,” and the testing schemas for certification. All in all, we expect most physicians in small practices to sit on the sidelines until the dust settles, likely in 2012 or 2013.

Nevertheless, while it is good to get Meaningful Use behind us, it may be better still seeing beyond it. After all, the incentive payments for becoming a “meaningful user of certified EHR technology” are merely a small down payment on the savings that could be realized if health care supply, delivery and payment are affected by the changing policy and market environments over the next 5 years. The EHR incentive programs are meant to prime the pump by putting approximately $25 billion, give or take a few billion, into the hands of physicians and hospitals who adopt EHR technology during the 5 years between 2011 and 2016.

During that same time, by comparison, reductions in waste, duplication, and unnecessary procedures might mean savings of $100 billion to Medicare alone,# depending on whose estimate you believe and how effective you think the reforms will be in replacing payment for volume with payment for value. It might be a lot more. Conservative estimates are that 30% of our total national health care expenditure of $2.5 trillion, or over $800 million, is unnecessary and could be eliminated through real reforms. Some authoritative estimates argue that half or more of care costs are unnecessary, so the target jumps to $1.25 trillion a year.

Remembering the Tonsillectomy Riots

Sep 2, 2010• 4

By MICHAEL MILLENSON

The humble tonsillectomy has been at the center of controversies over practice variation, inappropriate surgery and avoidable harm for decades; indeed, well before the terms to describe those problems were formally articulated. Now, thanks to the recently unearthedTonsillectomy Riots of 1906, you can add “patient empowerment” and “informed consent” to that list.

Tablet, an online magazine of Jewish news and culture, rescued theTonsillectomy Riots from historical obscurity. Piecing together old newspaper accounts in English and Yiddish, the magazine told what happened on New York’s heavily Jewish Lower East Side on a steamy day in June when “50,000 immigrant mothers descended on their local public schools demanding to see their children, having heard that there was a Board of Health-sanctioned child slaughter taking place.”Continue reading…

Getting Social

Sep 1, 2010• 1

By ROB LAMBERTS, MD

Moving to the south is an eye-opening experience. First, there’s the friendliness of everyone; I remember the first time a stranger talked to me in the grocery store, it made me nervous. In Philadelphia, where I went to med school, anyone talking to you in the grocery store was either hitting on you or crazy. Add to that list: “or from the south.”

Then there’s the politeness factor. Kids are expected to say “yes sir” and “yes ma’am” when answering questions asked by adults. Most northern-bred transplants to the south that I’ve talked to think this is a good thing – a refreshing change from the rudeness you often get from kids.

But perhaps the most foreign thing in coming to the south is something called “Social.” Social is a manners school where kids are not only taught how to eat right at the dinner table, but also how to address members of the
opposite sex and to perform various dances with a partner. The formal training happens around 6th grade, but the talk of who will get partnered with whom is fodder for many parental discussions for several years leading up to the actual course. Parents arrange partnerships between their children – kind of like arranged marriages. My two oldest kids participated in Social (which is run by a local family), and gave it mixed reviews. We didn’t force it (although we did get calls regarding our kids’ availability), and one of them liked it enough to do it three years, while another barely tolerated one.

All of this came to mind because of a phone call I got this morning requesting an interview about social media and the medical field. How are doctors handling blogs, Twitter, and Facebook? What are the guidelines I abide by, and should the professional societies (AMA, ACP, etc) be involved it directing their members on how to use social media? The interview was particularly timely because I was working on a post that quoted some funny patient/doctor interactions, but was having second-thoughts due to confidentiality concerns. How do I quote patient interactions without making it sound like I’m making fun of them?

Dipping Into the Waters of Mobile Health

Sep 1, 2010• 1

By CORA SHARMA

Introductory Remarks: Chilmark Research is pleased to welcome a new addition to our staff, Cora Sharma. Cora will be leading our research efforts in the mobile health app market (mHealth) and below is her first post on the subject.

The concept of mobility in healthcare is nothing new to providers, vendors, and to Chilmark Research alike. The current media and investor buzz surrounding mHealth stems from the belief that 1) mobile technology has finally matured to a point where age-old healthcare processes can finally be revamped; and 2) mobile technology has not only matured but has actually been adopted en-mass by physicians and shows no signs of abating.

Doctors Love Smartphones, but are GaGa over the iPad
Recent reports from SpyGlass Consulting and Manhattan Research show that the vast majority of physicians already use smartphones. Pamela Dolan at the AMA has a nice commentary on these latest numbers. Chilmark Research’s recent talks with industry folks shows that the iPad is also gaining significant traction with physicians. At a recent conference in Denver where Chilmark Research attended and spoke, the CIO of Catholic Health Initiative (CHI) sees providing their doctors with mobile apps (in CHI’s case on the iPad) as critical to the success of complying with meaningful use requirements.

mHealth Apps in Acute Care
Given that physicians have now ‘gone mobile’, does this imply that they will no longer be satisfied with computers-on-wheels (COWs), demanding mobile access to every piece of data buried in Health Information Systems (HIS)? If so, providing doctors with mobile access to patient and hospital data could be just the perk needed to attract more affiliated physicians, satisfy existing ones and ultimately drive the adoption and use of HIT by clinicians.Continue reading…

Dipping Into the Waters of Mobile Health

Sep 1, 2010

By CORA SHARMA

Introductory Remarks: Chilmark Research is pleased to welcome a new addition to our staff, Cora Sharma. Cora will be leading our research efforts in the mobile health app market (mHealth) and below is her first post on the subject.

The concept of mobility in healthcare is nothing new to providers, vendors, and to Chilmark Research alike. The current media and investor buzz surrounding mHealth stems from the belief that 1) mobile technology has finally matured to a point where age-old healthcare processes can finally be revamped; and 2) mobile technology has not only matured but has actually been adopted en-mass by physicians and shows no signs of abating.

Doctors Love Smartphones, but are GaGa over the iPad
Recent reports from SpyGlass Consulting and Manhattan Research show that the vast majority of physicians already use smartphones. Pamela Dolan at the AMA has a nice commentary on these latest numbers. Chilmark Research’s recent talks with industry folks shows that the iPad is also gaining significant traction with physicians. At a recent conference in Denver where Chilmark Research attended and spoke, the CIO of Catholic Health Initiative (CHI) sees providing their doctors with mobile apps (in CHI’s case on the iPad) as critical to the success of complying with meaningful use requirements.

mHealth Apps in Acute Care
Given that physicians have now ‘gone mobile’, does this imply that they will no longer be satisfied with computers-on-wheels (COWs), demanding mobile access to every piece of data buried in Health Information Systems (HIS)? If so, providing doctors with mobile access to patient and hospital data could be just the perk needed to attract more affiliated physicians, satisfy existing ones and ultimately drive the adoption and use of HIT by clinicians.

W(h)ither Insurers?

Aug 31, 2010• 16

By PAUL LEVY

The talk around the country among health insurance companies is that their insurance business is dying.

What is happening? First, the consolidations in other industries, resulting in large, multistate corporations, already mean that many companies self insure their employees. Even many local firms have large enough work forces that they can be self-contained risk pools. (One source I found says that in 2008, 89 percent of workers employed in firms with 5000 or more employees were in self-insured plans.) There is no sense compensating insurance companies for actuarial risk when your employee base is that large. Instead, the insurance companies or other firms are hired solely to administer the benefit plans.

For those insurance markets that still exist, the provisions for transparency under the national health care reform law, and the insurance exchanges that will be set up, will result in the commoditization of insurance products. That commoditization will drive down the profit margins that would otherwise exist in this market segment.

The result is that health insurance companies will become financial services organizations more than insurance entities. Think of them as another form of banking, where minimizing transaction costs becomes imperative, and where the use of derivatives and other hedges makes the difference in who makes money and who doesn’t.

This, in turn, also implies that scale matters. Like banks and credit card companies, the larger ones incur a lower cost for each transaction. Several years ago, I was told that the minimum size needed to be a successful insurance company was two million subscribers. That was before the national health reform bill passed.Continue reading…