Category: Medical Practice

TECH/HOSPITALS: Mr HISTalk says “Does Cerner Millennium kill children? I don’t think so.”

MrHISTalk, who’s blog is fantastic, out-does himself in an article about the University of Pittsburgh Children’s hospital CPOE implementation, which has had so much publicity since the article was released on Monday.

His article is called, Does Cerner Millennium kill children? I don’t think so. It’s not betraying his anonymity to tell you that MrHISTalk is a hospital IT director with a great deal of experience in pharmacy. He’s an expert, so go read it.

I have little to add other than three quick thoughts:

1) The before and after study may have studied a period too early in the CPOE implementation. It takes time to get the new processes down, and things may have got better later. But not in the timeframe of this study, apparently.

2) Last weekend I heard a doctor complaining bitterly about having to use an EMR in the outpatient setting, claiming that it imposed secretarial tasks on him, and interfered with his relationships with his patients. I’d counter by saying that in ambulatory care the recording of what happens in the exam room and the presentation of information from there and other venues (labs, medication) etc matters more to the care of the patient than the information that the doctor actually imparts there, 90% of which the patient forgets about when they walk out the door — something physicians don’t on the whole realize. In the ICU, what happens in the room is often a matter of life and death, so the interference that the recording of the information puts in the way of the process may have a bigger impact.

3) IT implementations are not easy. Paper does kill. Of course it’s not just paper that kills, it’s poor processes with or without IT. But the option of ignoring IT is not an option.  The industry needs to do much more work about getting this right.

POLICY: Yet more Dartmouth proof about doing too much

We’re almost at the point that you know exactly what any study from the Dartmouth group is going to find before it’s published. Following the assessment last year that showed that the nations “Top 100” hospitals show a wide variety of difference in procedures in their ICUs, for no apparent difference in outcomes, the same result comes up again.  This time (with Stanford’s Lauren Baker playing a starring cameo) Wennberg, Fisher et al looked at Medicare spending on patients in the last two years of life in hospitals in California and once again geography is destiny. (Health Affairs article here)

The study found that reimbursements ranged from $19,745 per Medicare patient at Redwood Memorial Hospital in Humboldt County’s Fortuna to $88,661 at Garfield Medical Center in Monterey Park in the San Gabriel Valley

Sacramento was cheaper than the Bay Area which was in turn cheaper than Los Angeles.  And of course the outcomes were similar in all places and had little relation to the costs. Interestingly, hospital chain is also a predictor. Sutter, which isn’t exactly known by California’s health plans as being a low cost operator, did way less than Tenet. (although I don’t know if Redding Medical Center skewed the data by itself!)

Medicare spending was also higher in some large hospital systems. Sutter Health, which operates 27 hospitals in Northern California, spent $30,814 on average per Medicare patient in the last two years of life, compared with $46,323 at Tenet Healthcare Corp.

Given that these are the most expensive patients (the 10% that cost 50% of all dollars), and moreover “it’s my money dammit”, you’d think that our so-called conservative leaders would be seizing on this to try to do something about the practice variation problem. But it just seems to be accepted as some type of unintelligent design.


PHYSICIANS: One doc’s look at his own care patterns

File this in the cleaning up my queue category, but there’s a pretty good article in last weeks NEJM about how a doctor judges himself.  I’d submit that apart from baseball players, and call center customer service rep, most of us don’t get the regular metricized feedback that would help us improve.

This doc, Richard Baron, surveyed a small sample of his practice and discovered (and I’m sure that he’s not alone) that although he and his staff were doing OK in servicing patients, and keeping them clinically in good shape, he was not doing so well communicating to them about how to manage their disease. So he needs to import a good dose of information therapy.

But this is a start. The only company I’ve ever worked where there was serious consultation via survey with staff and customers was a survey firm.  And to be fair, whatever the results of the survey, they didn’t seem to really change the organization’s behavior too much. Perhaps I should be surveying my clients and my readers….but I think many more doctors should be surveying their patients.


PHARMA/PHYSICIANS/POLICY: Oncologists getting paid for reporting data they should report anyway, by Gregory D. Pawelski

Congress has authorized the payment for oncologists reporting whether their treatment adheres to guidelines. Greg Pawelski, who follows the oncology market very carefully, was not too impressed.
When Senate Finance Committee Chairman Chuck Grassley found out that the value of the approximately $300 million-a-year medicare chemotherapy demonstration project to report on a patient’s level of nausea, vomiting, pain and fatigue was for nothing (providers were being paid $130 to simply forward the data that is already collected), they hoodwinked Congress into additional reimbursement to oncologists that report whether their treatment adheres to practice guidelines published by either NCCN or ASCO.

Looks like cancer patients will have to continue overpaying their oncologists and not have access to cutting-edge cancer treatments, and continue to suffer side-effect consequences and even death. The system will continue to serve the clinical investigators and the clinical oncologists, but not serve the best interests of cancer patients.

I think that the concept that some "authoritative" organization (made up primarily of practitioners and researchers with built in conflicts of interest) should determine the "correct" approach to cancer treatment has been very harmful to progress.

BLOGS/PHYSICIANS: Enoch Choi in New Orleans

oDr. Enoch Choi, a medblogger (and OT but BTW a liberal evangelical Christian just so you know there is one!) has packed up his black bag and spent the week in New Orleans following his medical calling.  Go read his blog and scroll down to the October 1 entry — then read up. Doesn’t take too long as he’s posting via his Treo and he’s mighty mighty busy. It’s an amazing read.

It’s very clear that the return to New Orleans is fraught with similar perils to the evacuation. Plaudits to Enoch to heading out and putting his God-given talents to work in a crisis. They still need doctors desperately down there.

UPDATE:  Enoch writes direct (promoted from the comments). Please consider donating once more to the organizations that are sending committed volunteers like him onto the very front lines.

thanks for the props, Matthew. i’ve come to new orleans with City Team ministries and serving under the local authority of Pastors Resource Council PRC Compassion, invited by the local churches in St. Bernard. Menlo Park Presbyterian Church MPPC paid all of our flights, expenses, medicines and supplies.

Any of those organizations would be able to immediately deploy your donations to people we’re seeing every day. Yesterday, one of our nurses gave us $1000 from their Kansas Church… Their entire disposable cash. We spent it today on natural tears, sunblock, nasal saline, sudafed, lozenges, cough syrup, hydrocortisone. We gave it away in 2 hours. There’s immesurable need here, and whatever you give to MPPC would be immediately consumed by that need by our medical team.

to give to MPPC:

to give to City Team:

to give to PRC Compassion:

This is so different than giving to Red Cross, what you give to them will be spent on the next disaster. The Red Cross doesn’t have physicians down here. I don’t see any other medical teams down here other than ours. There are plenty of individual physicians that have come down, and they’re very important, but as an organized group, we’re it.

PHYSICIANS/POLICY: Malpractice explained

Susan Sheridan, whom I wrote about last month, is even more famous. She and her son Cal who has kernicterus syndrome are the hook for a piece in The New Republic by Robert Berenson. (You may only be able to get to the first page…) It largely tells the truth about malpractice, but just to reiterate, my reading of the data is that:

1) The tort system only picks up about half of malpractice2) The medical system barely ever apologizes (Susan never got an apology), but when it does law suits are much less likely3) Too much of the money goes to lawyers and expert witnesses, and lawyers and Democrats don’t want to change that, but as they don’t hold power–so what.4) Doctors, whose Republican allies now do hold power, are only interested in reducing caps on damages, which may reduce their rates a bit but does nothing to help severely injured victims of malpractice and more importantly nothing much to reduce medical costs for the rest of us. (I live in California where we have the MICRA caps and my insurance premiums ain’t going down — sufficient proof to me that the Republican talking points about this are bunk).5) Defensive medicine makes the system and the doctors more money and until they stop getting paid for it, the whole "8-10% savings" concept is a myth6) Special courts, non-binding arbitration, apologies, openness, and a near-miss reporting system are all good ideas and are the eventual solution, but the AMA won’t back them, and their Republican allies won’t either. Why not? For them tort reform has nothing to do with patients, and not much to do with doctors, but much, much more to do with stopping what are mostly legitimate lawsuits against malfeasant corporations — and it’s much better if that all gets mixed up with an evil lawyer suing Marcus Welby MD in their PR campaign.

So unless there is some real concession from organized medicine, we’ll keep what we’ve got and it doesn’t work.  The "good" news is that it’s only a minor issue compared to the complete morass of the rest of the health care system.

(Hat-tip to Brian Klepper for the article)

PHARMA/PHYSICIANS: Trying to stop the biting of the feeding hand

So there’s a bunch of rabble-rouser docs who are actually trying to enforce the often mouthed concept that doctors shouldn’t take freebies from pharma companies. They’re called No Free Lunch

And of course, given the actual views of mainstream doctors who believe that life was better when the pharma companies had no restrictions on the graft they could send their way, they are being banned by specialty societies from doing things like handing out the specialty societies own guidelines on gift-receiving to its members, and of course from buying a booth at the oh-so-well incorruptible AAFP’s convention. Jim Edwards at Brandweek has more. But let’s not be too surprised.

PHYSICIANS/POLICY: Another Podcast with Eric Novack

So here’s another podcast recorded at the tail end of last week with me chatting with surgeon, talk radio host and "free-market" advocating surgeon Eric Novack. This one focuses on why health care costs so much and why we can’t stop physicians behaving badly. We discuss evidence-based medicine, managed care, capitation, end of life care, practice variation, and defensive medicine — and it’s still incredibly civilized. Don’t worry — we’ll keep having these talks until we really start laying into each other!

Here’s the MP3 to download (this one’s a little over 30 minutes listening time). Enjoy and please tell me what you think



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