On April 29, Dr. Daniel Croviotto published an editorial in the Wall Street Journal, “A Doctor’s Declaration of Independence,” in which he argued that it is time to “defy healthcare mandates issued by bureaucrats not in the healing profession.”
Dr. Croviotto does a good job of articulating his frustration with the increasingly burdensome bureaucracy and regulations placed on care. Many physicians and nurses share his frustration. I once did, until I saw a way out of the cynicism and frustration – a way that can improve the quality and lower the cost of care for all Americans.
No matter how misguided we think the federal government is in its electronic health record mandate or other requirements, simply defying mandates as Dr. Croviotto proposes is not likely to accomplish much. Those who signed the Declaration of Independence knew it was only an initial step toward ridding the country of tyranny. They had to create a new vision for a better, more effective government.
Similarly, the medical profession needs to move beyond cynicism to create a vision for a better, more effective healthcare system.
Scott Erven is head of information security for a healthcare provider called Essentia Health, and his Friday presentation at Chicago’s Thotcon, “Just What The Doctor Ordered?” is a terrifying tour through the disastrous state of medical device security.
Wired’s Kim Zetter summarizes Erven’s research, which ranges from the security of implanted insulin pumps and defibrillators to surgical robots and MRIs. Erven and his team discovered that hospitals are full of fundamentally insecure devices, and that these insecurities are not the result of obscure bugs buried deep in their codebase (as was the case with the disastrous Heartbleed vulnerability), but rather these are incredibly stupid, incredibly easy to discover mistakes, such as hardcoded easy default passwords.
For example: Surgical robots have their own internal firewall. If you run a vulnerability scanner against that firewall, it just crashes, and leaves the robot wide open.
The backups for image repositories for X-rays and other scanning equipment have no passwords. Drug-pumps can be reprogrammed over the Internet with ease. Defibrillators can be made to deliver shocks — or to withhold them when needed.
Doctors’ instructions to administer therapies can be intercepted and replayed, adding them to other patients’ records.
You can turn off the blood fridge, crash life-support equipment and reset it to factory defaults. The devices themselves are all available on the whole hospital network, so once you compromise an employee’s laptop with a trojan, you can roam free.
You can change CT scanner parameters and cause them to over-irradiate patients.Continue reading…
Did you hear the one about the CMS administrator who was asked what it would take to delay the 2014 ICD-10 implementation deadline? An act of Congress, he smugly replied, according to unverified reports.
Good thing he didn’t say an act of God.
So, now that CMS has been overruled by Congress, who wins and who loses? Who’s happy and who’s not?
The answers to those questions illustrate the resource disparity that prevails in healthcare and, mirroring the broader economy, threatens to get worse. The disappointed Have-a-lot hospitals are equipped with the resources to meet ICD-10 deadlines and always felt pretty confident of a positive outcome; the Have-not facilities were never all that sure they would make it and are breathing a collective sigh of relief.
First off, it is necessary to recognize that ICD-10 is far superior to ICD-9 for expressing clinical diagnoses and procedures. Yes, some of the codes seem ridiculous … “pecked by chickens,” for example. But people do get pecked by chickens, or plowed into by sea lions, so I believe the intent is positive, as will be the results.
An example: I saw my physician this past week at a Have-a-lot health system in San Francisco and I asked what she thinks of the ICD-10 extension.
“We’re already using (ICD-10) in our EHR and it is much better than ICD-9,” she said. “When I want to code for right flank pain, it’s right there. I don’t have to go with back pain or abdominal pain and fudge flank in. It’s easier and more accurate.”
“If I was still on paper and not our EHR, which I like,” she added, “my superbill would go from 1 page to 10. SNOMED works.”
Sorry to get all Katie Couric on you, but I’m going to have a colonoscopy on Friday. I turned 40 last October and I have some family history that leads my doctor to get one done now rather than at 50.
Unlike Katie, I won’t be broadcasting mine live, but I’ll share some articles and reflections on the process and, being process focused, what could go wrong. It’s a very necessary procedure, but there are, sadly, some very unnecessary and preventable risks.
Maybe I should have asked what my physician’s complication rates are. What are the complication rates at the surgical center where this will be done? Is this safer than being at a full-blown hospital or doesn’t it matter? Should I be more of an “engaged patient?”
Should I have asked more questions of my primary care provider? Why did she refer me to this GI specialist? Is he a “Best” doctor? Does that matter?
If I treat them as a supplier (respectfully), should I be able to walk the process and see what they do to prevent, say, instrument or scope disinfection errors?
Should I have asked:
Show me how you disinfect the equipment
Show me your training records for the people doing this work
Show me your equipment maintenance records
How do you verify that the work is being done properly?
Have you had any complaints or incidents in the past?
I had my pre-procedure phone call on Monday. Maybe I should follow up and ask a few of these questions, even if I can’t go “walk the gemba” to check things out myself. What would you do?
Of course, I didn’t have data or information available to me to know:
Which specialist is best at this?
Who has the highest or lowest complication rates?
What are the prices for different doctors or locations?
I don’t know how a busy person makes an informed decision.
I’m just back from the annual meeting of the Society of Hospital Medicine and, as usual, I was blown away. I’ve not seen a medical society meeting that is remotely like it.
As Win Whitcomb, who co-founded SHM, wrote to me, the meeting is “a mix of love, deep sense of purpose, community, mission, changing-the world, and just plain sizzle,” and I completely agree. I was also amazed by the size: having hosted the first hospitalist meeting in 1997, with about 100 people, seeing an audience of 3,600 fill a Las Vegas mega-ballroom was just plain awesome.
This enthusiasm did not equal smugness. Folks know that change is the order of the day, and with it will come upheaval and some unpleasantness. But the general attitude I sensed at the meeting was that change is likelier to be good for patients – and for the specialty – than bad. Whether this will ultimately be true is up in the air, but the mindset is awfully energizing to be around.
Here, in no particular order, is my take on a few of the issues that generated hallway buzz during the SHM meeting.
The Closing of Hospitals
While much is uncertain in the era of health reform, the number of hospitals is clearly going to shrink, perhaps by a lot. A healthcare system that tolerated the inefficiency of having two mediocre 125-bed hospitals in adjacent towns will no longer do so: one 200-bed hospital will be left standing when the dust settles.
The betting is that 10-20% of hospital bed capacity will be taken out of the system in the next few years. It could be even more, depending on the answers to several questions. Will electronic monitoring and telemedicine allow increasing numbers of sick patients to be cared for at home or in sub-acute settings?
Will payments for non-hospital care (home care, SNFs) be enough to expand their capacity to care for acutely ill patients?
Will ACOs, bundling, and other similar interventions truly flourish? Will a shift to population health and a new focus on wellness make a dent in the prevalence of chronic disease?
In ancient Athens, the philosopher Diogenes wandered the daylight markets holding a lantern, looking for what he termed, “an honest man.”
It seems since the dawn of the consumer economy that customers and buyers have traded most heavily on a single currency – trust.
Three millennia later, our financial system still hinges on the basic premise that the game is not rigged and any trusted intermediary is defined by a practitioner who puts his client’s interests ahead of his own.
Anyone responsible for procurement of healthcare may feel like a modern-day Diogenes as they wander an increasingly complex market in search of transparent partners and aligned interests. The art of managing medical costs will continue to be a zero-sum game where higher profit margins are achieved at the expense of uninformed purchasers.
It’s often in the shadowed areas of rules-based regulation and in between the fine print of complex financial arrangements that higher profits are made.
Are employers too disengaged and outmatched to manage their healthcare expenditures?
Are the myriad intermediaries that serve as their sentinels, administrators and care managers benefiting or getting hurt by our current system’s lack of transparency and its deficit of information?
In 1980, while working at the University of Chicago Pritzker School of Medicine, I wrote an article for the Harvard Business Review entitled “The Health Care Market: Can Hospitals Survive?”. This article, and the book which followed, argued that hospitals faced a tripartite existential threat:
1) ambulatory technologies that would enable physicians to compete successfully with hospitals at lower cost in their offices or freestanding settings, 2) post-acute technologies that would enable presently hospitalized patients to be managed at home and 3) rapidly growing managed care plans that would “ration” inpatient care and bargain aggressively to pay less for the care actually provided.
I predicted a significant decline in inpatient care in the future, and urged hospitals to diversify aggressively into ambulatory and post acute services. Many did so. A smaller number, led by organizations like Henry Ford Health System of Detroit and Utah’s Intermountain Health Care, also sponsored health insurance plans and became what are called today “Integrated Delivery Networks” (IDN’s).
In the ensuing thirty years, US hospital inpatient census fell more than 30%, despite ninety million more Americans. However, hospitals’ ambulatory services volume more than tripled, more than offsetting the inpatient losses; the hospital industry’s total revenues grew almost ten fold.
Ironically, this ambulatory care explosion is now the main reason why healthcare in the US costs so much more than in other countries. We use far fewer days of inpatient care than any other country in the world. But as the McKinsey Global Institute showed in 2008 ambulatory spending accounts for two thirds of the difference between what the US spends on healthcare and what other countries spend, far outstripping the contribution of higher drug prices or our multi-payer health financing system.
We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.
National Quality Improvement Initiatives
Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals.
We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others.
To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change: “You cannot go from imperfect to perfect. It’s a slow process.”
There are many stories of patients who suffer when we make errors prescribing antibiotics. 75-year-old Bob Totsch from Coshocton, Ohio, went in for heart bypass surgery with every expectation of a good outcome.
Instead, he developed a surgical site infection caused by MRSA. Given a variety of antibiotics, he developed the deadly diarrheal infection C. difficile, went into septic shock, and died.
A tragic story and, probably, a preventable death.
Today, we’ve published a report about the need to improve antibiotic prescribing in hospitals. Antibiotic resistance is one of the most urgent health threats facing us today. Antibiotics can save lives.
But when they’re not prescribed correctly, they put patients at risk for preventable allergic reactions, resistant infections, and deadly diarrhea. And they become less likely to work in the future.
About half of hospital patients receive an antibiotic during the course of their stay. But doctors in some hospitals prescribe three times more antibiotics than doctors in other hospitals, even though patients were receiving care in similar areas of each hospital.
Among 26 medical-surgical wards, there were 3-fold differences in prescribing rates of all antibiotics, including antibiotics that place patients at high risk for developing Clostridium difficile infections (CDI).
CDC has estimated that there are about 250,000 CDIs in hospitalized patients each year resulting in 14,000 deaths.
As the fashionistas might say, transparency in health care is having a moment. It made the PricewaterhouseCoopers top 10 list for 2014 industry issues, and there is every reason to expect transparency to be very visible this year and beyond.
Without a doubt, transparency is hot.
Despite this, there is increasing grumbling by observers who say that transparency is complicated and hard to operationalize. We also hear that transparency is “not enough” to constrain costs in our dysfunctional system, especially in the face of provider market power.
The word itself invites skepticism, in that it seems to over-simplify and promise a magical solution, as if daylight will provide health care pricing with a glow of rationality.
As usual, the truth lies somewhere in the middle. Transparency can and will provide information about price, quality, and consumer experience that market participants need in order to better understand the health care system and increase its value.
While this information is surely necessary, we have seen many examples of when it is not sufficient. Clearly, transparency is not the only tool that we need.
Here are a few thoughts about transparency issues for 2014.
Transparency tools will hit Main Street.
Increasingly, consumer-facing tools with various kinds information about health care prices are being created, whether it is okcopay or Change Healthcare. These entries join a growing list of transparency tools from carriers or third-party vendors.
The Robert Wood Johnson Foundation’s Hospital Price Transparency challenge, designed to promote awareness of hospital charge data, had a record number of entrant and the winning submissions are downright inspiring. RWJF also awarded grants for research on the use of price data in health care, including a number of studies of promising transparency tools aimed at consumers and providers.
The field is becoming more crowded, and it is increasingly important to determine the optimal way to reach the consumer with price and quality information.
There will be greater focus on the customer experience.
There is no doubt that the customer experience in health care lags behind the rest of the service sector, and consumers are increasingly demanding responsiveness and convenience in their encounters with the medical profession. The growth of evening and weekend hours, email communications with physicians, and patient portals are all harbingers of a new age where medicine is far more customer friendly.
RWJF’s Open Notes initiative allows patients to share notes with their doctors, while the Foundation’s Flip the Clinic program completely reimagines the doctor patient encounter in the ambulatory care setting.