The Wall Street Journal recently contacted me regarding an upcoming article on Sedasys, the new gadget that is supposed to be able to infuse propofol by computer while monitoring vital signs.
If you’ve read anything I’ve written previously, you’ll know that I am NOT a big proponent of technology as a means of “improving” patient care. To me, the more technology you put between the patient and the caregiver, the less medicine you’re practicing, and the more data-entry and computer programming you’re doing.
Sedasys is designed specifically to administer propofol. Propofol is a milk-like substance that produces a range of effects from sedation to general anesthesia. For sedation you just use less, for general anesthesia you use more. Its very quick onset and very quick recovery make it great for outpatient sedation. It has to be given in a continuous drip because its effect goes away so fast. GI docs love it because its so effective. I suspect they also love it because propofol comes with an anesthesiologist to give it.
The only problem is the one Michael Jackson encountered: it has this pesky side effect of causing you to stop breathing. And you can’t tell by looking at a person how much will sedate them and how much will make them stop breathing.
A little old lady with a million health problems might sedate at, say, 40 mg and stop breathing at 60 mg, while an 19-year-old could probably take 150 mg and still be fighting you. It’s not necessarily weight-based.
If one were writing about the improvement of gastronomy in America, one would probably not celebrate “over 300 billion hamburgers served.” But that’s very much the type of success Dr. Ashish Jha is celebrating in last week’s piece on recent US healthcare IT sales. Unfortunately, the proliferation of Big Macs does not reflect superior cuisine, and healthcare IT (HIT) sales do not equate with better healthcare or with better health. Quantity does not equal quality of care.
To be sure, Dr. Jha acknowledges the challenges of rolling out HIT throughout US hospitals. And he should be strongly commended for his admission that HIT doesn’t capture care by many specialists and doesn’t save money. In addition, Dr. Jha points to the general inability of hospitals, outpatient physicians and laboratories to transfer data among themselves as a reason for HIT’s meager results.
But this is a circular argument and not an excuse. It is the vendors’ insistence on isolated proprietary systems (and the government’s acquiescence to the vendors) that created this lack of communication (non-interoperability) which so limits one of HIT’s most valuable benefits.
In our opinion, the major concern is that the blog post fails to answer the question we ask our PhD students:
So what? What is the outcome?
This entire effort is fueled by $29 billion in government subsidies and incentives, and by trillions of dollars spent and to be spent by hospitals, doctors and others .
So where is the evidence to back up the government’s and industry’s promises of lower mortality, improved health and lower health care costs?
Single studies tell us little. Sadly, as many as 90% of health IT studies fail the minimal criteria of the respected international literature syntheses conducted by the Cochrane Collaboration.
In other words, studies with weak methodology or sweetheart evaluation arrangements just don’t count as evidence. Continue reading…
Ignaz Semmelweiss was laughed out of his Viennese hospital when he suggested that physicians should wash their hands in between conducting an autopsy and delivering a baby.
150 years later, we know just how right he was, but hand sanitation compliance rates at hospitals still hover in the 30% to 50% range. This makes it easy for hospital-acquired infections (HAIs) such as MRSA and VRE to run rampant, a (literally) dirty, not-so-little, and not-so-secret reality for American patients.
A Healthbox-backed startup is trying to change that. SwipeSense, founded in 2012 by Northwestern University graduates Mert Iseri and Yuri Malina, is a system designed to improve sanitation practices in hospitals using portable hand sanitizers and wirelessly-collected data on their use.
The organization wants to help stem the tide of avoidable HAIs. Each year, about 100,000 Americans die from infections they contract during their time in the hospital – more than the number of Americans killed by guns, motor vehicles, and leukemiacombined. In addition to the direct human toll, HAIs cause patient length of stays to increase by 8.0 days in ICUs and 7.4 to 9.4days in acute care wards, taking up expensive capacity and preventing others from accessing needed hospital beds. They’re also expensive, causing an estimated $4.5 to $5.7 billion in excess costs.
Iseri and Malina were inspired to create SwipeSense by a project they did for Design for America, a student group created to catalyze social change using human-centered design (also founded by Iseri and Malina). It took them to Northwestern Memorial University Hospital in their college town of Evanston, Illinois, where they identified two salient issues with hand sanitation: convenience and compliance.
“It’s obvious it’s not the fault of the nurse or physician…it’s something wrong with the system,” Malina told me in an interview. Even though alcohol foam and soap dispensers are ubiquitous in American hospitals, they often aren’t at the immediate point of care: “medical staff need to sanitize four or five times per patient encounter,” Malina said, making proper sanitation an arduous, time-consuming, and unrealistic task. “Our philosophy at SwipeSense is that the right thing to do should be the easiest thing to do… We want to make something that people love.”
Yesterday was my last day as chair of the ABIM, and the end of my eight-year tenure on the Board. In this blog – a bookend to the one I wrote at the start of the year, which went near-viral – I’ll describe some of our accomplishments this year and a few of the challenges that I leave my talented successors to grapple with.
I had two very tangible tasks to accomplish during my chairmanship. First, after a decade-long tenure as CEO and President of ABIM, Chris Cassel announced her intention to step down. (Chris is now CEO of the National Quality Forum, which is increasingly crucial in a world looking for robust measures of quality, safety, and value.) After an extensive search, we selected Richard Baron to become ABIM’s new CEO, and Rich began earlier this month. Rich is one of the most impressive people I’ve met in healthcare, and a perfect choice to lead ABIM into the future. As someone who practiced general internal medicine for nearly three decades in a mid-sized Philadelphia office, he is a “doctor’s doctor.”
He is intimately familiar with the work of the Board, having served on the boards of both ABIM and the ABIM Foundation for over a decade (including a year as ABIM chair). He also has extensive policy experience, most recently as director for Seamless Care Models for the Center for Medicare & Medicaid Innovation (CMMI), where he was responsible for putting meat on the bones of concepts like the “Medical Home” and “Accountable Care Organization.” Rich is wickedly smart, a superb communicator, and a great listener with impeccable values and an unerring ethical compass. He’ll be splendid.
The second area may be a bit more Inside Baseball, but will ultimately be just as important. A couple of years ago, we began a process to redesign the ABIM’s governance. Our 28-person board was both too large and had too much on its plate for effective decision making. In work that was superbly led by then-chair Catherine Lucey, assisted by a crack committee, staff and governance expert Jamie Orlikoff, we decided to transform our governance structure. As of tomorrow, the ABIM board shrinks to 15 members – chosen for their experiences and competencies rather than because they represent a given medical subspecialty – and a new group, the ABIM Council, is formed.Continue reading…
There is a consensus that measuring performance can be instrumental in improving value in U.S. health care. In particular clinical areas, such as cardiac and intensive care, measurement has been associated with important improvements in providers’ use of evidence-based strategies and patients’ health outcomes over the past two decades. Perhaps most important, measures have altered the culture of health care delivery for the better, with a growing acceptance that clinical practice can and should be objectively assessed.
Nevertheless, as we argue in the full-length version of this paper, substantial shortcomings in the quality of U.S. health care persist. Furthermore, the growth of performance measurement has been accompanied by increasing concerns about the scientific rigor, transparency, and limitations of available measure sets, and how measures should be used to provide proper incentives to improve performance.
The challenge is to recognize current limitations in how measures are used in order to build a much stronger infrastructure to support the goals of increased accountability, more informed patient choice, and quality improvement. In the following paper, we offer seven policy recommendations for achieving the potential of performance measurement.
1. Decisively move from measuring processes to outcomes.
There is growing interest in relying more on outcome measures and less on process measures, since outcome measures better reflect what patients and providers are interested in. Yet establishing valid outcome measures poses substantial challenges—including the need to riskadjust results to account for patients’ baseline health status and risk factors, assure data validity, recognize surveillance bias, and use sufficiently large sample sizes to permit correct inferences about performance.
2. Use quality measures strategically, adopting other quality improvement approaches where measures fall short.
While working to develop a broad set of outcome measures that can be the basis for attaining the goals of public accountability and information for consumer choice, Medicare should ensure that the use of performance measures supports quality improvement efforts to address important deficiencies in how care is provided, not only to Medicare beneficiaries but to all Americans. CMS’ current focus on reducing preventable rehospitalizations within 30 days of discharge represents a timely, strategic use of performance measurement to address an evident problem where there are demonstrated approaches to achieve successful improvement . Read more.
I sometimes explain to medical students that they are entering a profession being transformed, like coal to diamonds, under the pressure of a new mandate. “The world is going to push us, relentlessly and without mercy, to deliver the highest quality, safest, most satisfying care at the lowest cost,” I’ll say gravely, trying to get their attention.
“What exactly were you trying to do before?” some have asked, in that wonderful way that smart students blend naiveté with blinding insight.
It is pretty amazing that healthcare has been insulated from the business pressures that everybody from Yahoo! to my father’s garment business have experienced since the days of Adam Smith. We experienced a bit of this pressure in the mid-1990s, when pundits declared healthcare inflation “unsustainable” (sound familiar?) and we invented managed care to slay it. We know how that story ended – the public and professional backlash against HMOs defanged the managed care tiger to the point that it could barely produce a “meow.” The backlash was followed by a 15-year run during which efforts to slash healthcare costs have been remarkably meager.
That run has ended.
Luckily, while we’ve been let off the hook on cost-reduction, we’ve not been given a free pass on improvement. Beginning with the Institute of Medicine reports on safety (2000) and quality (2001), we have been under growing pressure to improve the numerator of the value equation: patient safety, quality of care, and patient satisfaction. Particularly for those of us who work in hospitals, we now feel this pressure from many angles: from accreditors (more vigorous and unannounced Joint Commission inspections, residency duty hour limits), transparency (Medicare’s Hospital Compare), comparative measurement (HealthGrades, Leapfrog, Consumer Reports and many other hospital rankings), and, most recently, payment policies (no pay for “never events,” penalties for readmissions, value-based purchasing, and “Meaningful Use” standards for IT).
These initiatives have created an increasingly robust business case to improve. Hospitals everywhere have responded with new resources, committees, ways of analyzing data, educational programs, computer systems, and more.
There is growing interest in relying more on outcome measures and less on process measures, since outcome measures better reflect what patients and providers are interested in. Yet establishing valid outcome measures poses substantial challenges—including the need to riskadjust results to account for patients’ baseline health status and risk factors, assure data validity, recognize surveillance bias, and use sufficiently large sample sizes to permit correct inferences about performance. We believe the operational challenges of moving to producing accurate and reliable outcome measures, though daunting, are worth the effort to overcome.
Patients, payers, policy-makers, and providers all care about the end results of care—not the technical approaches that providers may adopt to achieve desired outcomes, and may well vary across different organizations. Public reporting and rewards for outcomes rather than processes of care should cause provider organizations to engage in broader approaches to quality improvement activities, ideally relying on rapid-learning through root cause analysis and teamwork rather than taking on a few conveniently available process measures that are actionable but often explain little of the variation in outcomes that exemplifies U.S. health care.
However, given the inherent limitations of administrative data, which are used primarily for payment purposes, and even clinical information in electronic health records (EHRs), consideration should be given to developing a national, standardized system for outcome reporting . A new outcome reporting system would not be simple or inexpensive, but current data systems may simply be insufficient to support accurate reporting of outcomes. An example is the National Health Care Safety Network system for reporting health care infections .
If you follow the world of higher education, you have heard of MOOCs—massive online open courses. Open to anyone, anywhere, these free classes can attract tens of thousands of students whose hunger to learn outweighs the fact that no credits are typically awarded. With many elite universities now offering MOOCs, it’s a movement that is worth following as a potential model for affordable, accessible education in the future.
From an educator’s perspective, it’s also worth trying out. Beginning June 3, I will be teaming up with Cheryl Dennison Himmelfarb, a patient safety expert and associate professor at the Johns Hopkins University School of Nursing, to lead a five-week-long MOOC, “The Science of Safety in Healthcare.” Through the course, participants will explore fundamental topics in the science of safety, patient safety culture, teamwork and communication, patient-centered care, and strategies for assessing and improving care. The course workload is two to five hours per week, which includes up to two hours of video instruction, as well as readings and assignments.
Clinicians, hospital administrators, students, patients—indeed anyone with an interest in this topic—should consider enrolling. Students receive a statement of accomplishment upon passing the course.
Increasing patient safety requires that all frontline health care workers understand the basic concepts and language of health care, and that they develop the lenses to identify the hazards that face their patients. It will be interesting to see, through this course, if the MOOC model can help to efficiently deliver that kind of education on a broad basis. Certainly, becoming a patient safety leader at your unit, department or hospital requires more in-depth training.
Q: Have hospitals improved since the first Hospital Safety Score last year?
A: We saw an incremental improvement in the scores, though it is not as rapid or as dramatic as we would like. For the Spring 2013 Hospital Safety Score, there were more than 2,500 general hospitals scored, including 780 “As,” 638 “Bs,” 932 “Cs,” 148 “Ds” and 16 “Fs.” Those hospitals that lowered their grades demonstrate how patient safety can be seriously impacted when hospitals don’t stay vigilant. Safety is a 24/7, 365-day effort with all hands on deck; there is no time for excuses when it comes to preventing errors, injuries and harm. On the other hand, hospitals that showed improvement should be celebrating. They have clearly accepted the challenge to improve and have proven that any institution can make significant advances in patient safety over a short period of time. Now, they need to work on sustaining that achievement into the future.
Q: How is the Hospital Safety Score different from other hospital ratings?
A: The Hospital Safety Score is the standard assessment of how well hospitals perform at protecting patients from accidents, errors and injuries. The Score is 100-percent transparent, and the only hospital safety assessment to be (favorably) peer-reviewed in the Journal of Patient Safety. Unlike any other rating, you can see all the data that was applied to every scored hospital, as well as the entire methodology. Also unlike many other ratings, the Hospital Safety Score highlights both the best and poorest performers on safety in an effort to educate consumers on the hospitals they rely on for care.
The Hospital Safety Score assesses hospitals strictly on patient safety. Each “A,” “B,” “C,” “D,” or “F” score assigned to a hospital comes from expert analysis of infections, injuries, and medical and medication errors that frequently cause harm or death during a hospital stay.
The small news is that I formally joined Patient Privacy Rightsas chief technology officer. I have been an extreme advocate for open data for years. For example, I’m a card-carrying member of the Personal Genome Project where I volunteer to post both my genome and most of my medical record. PPR, on the other hand, is well known for publicizing the harms of personal data releases. These two seemingly contradictory perspectives represent the matter-antimatter pair that can power the long march to health reform.
The value of personal medical data is what drives the world of healthcare and the key to health reform. The World Economic Forum says: “Personal data is becoming a new economic “asset class”, a valuable resource for the 21st century that will touch all aspects of society.” This “asset” is sought and cherished by institutions of all sorts. Massive health care organizations, research universities, pharmaceutical companies, and both state and federal regulators are eager to accumulate as much personal medical data as they can get and to invest their asset for maximum financial return. Are patient privacy rights just sand in the gears of progress?