Virtual visits are increasingly the rage amongst forward-thinking healthcare providers that want to jump on the telehealth band wagon. Extending the office visit across distance, using the same technology we use to keep in touch with loved ones (videoconferencing such as Skype and FaceTime), is a safe and logical way for providers to venture into a new tech-enabled world that may still be scary for some.
One way to think of this trend is to consider virtual visits an extension of the brick and mortar care model made famous a decade ago by companies like Minute Clinic. Offer convenient access to a care provider for a limited number of conditions.
Virtual visits can take place by either video or voice connection. These interactions are most often for indications that are non-life threatening, acute problems such as sore throat, ear ache, urinary tract infection and the like. There is also a role for this technology in follow up care for conditions such as diabetes and hypertension, but for this post we’ll focus on acute care.
It’s done. Congress on April 14 passed and the president signed into law a bill that terminates one of the most egregious and silliest examples of dysfunctional government in recent years—the so-called “sustainable growth rate” (SGR) formula for doctors’ fees under Medicare.
First, a round of applause for bipartisan agreement—however obvious it was that had to happen in this case. The vote in the house was 392-37. In the Senate, it was 92-8.
Praise is also in order for enacting two more years of funding for the Children’s Health Insurance Program and $7.2 billion in new funding over two years for community health centers, a program that was expanded under the Affordable Care Act and serves low-income families. There’s also welcome help for low-income Medicare beneficiaries and rural hospitals.
But the main thrust of the law is to kill one (failed) program that adjusted doctors’ fees under Medicare and create a new and hopefully better one.
I’ve written several posts about the frustrating aspects of Meaningful Use Stage 2 Certification. The Clinical Quality Measures (CQMs) are certainly one of problem spots, using standards that are not yet mature, and requiring computing of numerators and denominators that are not based on data collected as part of clinical care workflow.
There is a chasm between quality measurement expectations and EHR workflow realities causing pain to all the stakeholders – providers, government, and payers. Quality measures are often based on data that can only be gathered via manual chart abstraction or prompting clinicians for esoteric data elements by interrupting documentation.
How do we fix CQMs?
1. Realign quality measurement entity expectations by limiting calculations (call it the CQM developers palette) to data which are likely to exist in EHRs. Recently, Yale created a consensus document, identifying data elements that are consistently populated and of sufficient reliability to serve in measure computations. This is a good start.
Forget for a moment the familiar scenes of action and outraged reaction that are playing out in our long-running national debate over how best to provide access to health care for every American. Instead, ask one simple question: what happens in the doctor’s office or hospital once access is achieved.
I set out to write a book addressing that question almost twenty years ago. I thought myself well qualified: I’d written about health care for a decade for the Chicago Tribunewhile receiving various awards and other recognition. But it didn’t take long for a painful realization to set in of how naïve I really was.
Digging through hundreds of studies, articles and other first-hand sources stretching back for decades, I was stunned to discover that repeated evidence of unsafe, ineffective, wasteful and downright random care had had no effect whatsoever on how doctors treated patients. Literally none. Moreover, the few professionals who understood this truth couldn’t talk about it in public without endangering their careers or engendering vitriol from peers.
From ulcers to urinary tract infections, tonsils to organ transplants, back pain to breast cancer, asthma to arteriosclerosis, the evidence is irrefutable. Tens of thousands of patients have died or been injured year after year because readily available information was not used – and is not being used today – to guide their care. If one counts the lives lost to preventable medical mistakes, the toll reaches the hundreds of thousands.
The only barrier to saving these lives is the willingness of doctors and hospital administrators to change.
Demanding Medical Excellence came out in October, 1997. What progress has been made since then, and where we have fallen short? I address that question in a short article, “The Long Wait for Medical Excellence,” in the October, 2013 issue of Health Affairs. The purpose of this blog entry is to recap some of what’s said there (for you non-subscribers) and to add a few impolite observations that don’t jibe with the rules of a peer-reviewed journal.
On a warm and sunny August Sunday, I was rollerblading with my kids on the Shining Sea Bikeway. On mile nine on the trip, I hit a tree root, went flying, and landed on my shoulder. I could tell immediately that something was wrong — I couldn’t move my arm and was in the worst pain of my life. Feeling for my left shoulder, it was obvious that I had dislocated it. What happened next was that I received some of the best care of my life – unfortunately it was not from our healthcare system.
As I was lying on the bike path, nearly everyone stopped and asked how they could help. A pediatric nephrologist offered to pop my shoulder back into place. I declined. This wonderful couple on a two-person reclining bike stopped and insisted on pedaling me to the hospital. We were far from the road and knew that calling an ambulance was not straightforward. So I sat with my left arm dangling, in excruciating pain, while David rode the bike to Falmouth Hospital. It was a 20 minute ride finishing with a very steep hill. David apologized after each bump on the road as he heard me swear and wince.
The Emergency Room:
We finally made it to the ER, and, ironically, it was then that my care stopped being so wonderful.
It started off well enough – a triage nurse saw me walking in holding my arm, in distress. She got me a wheelchair and brought me into triage. I explained what happened, gave my name, date of birth and described the pain as the worst of my life. I was then shuttled to registration, where I was asked to repeat all the same information. It felt surreal: I had moved all of 10 feet and yet somehow my information hadn’t followed me. The registration person asked me question after question. Initially, the same ones: name, address, phone #, etc. Then, my Social Security number (presumably so they could go after me if I didn’t pay my bill), my primary care physician’s name, his address, his phone #, my insurance status, my insurance #, my insurance card, my emergency contact, their address and phone #, etc. etc. etc.
I told her I was in excruciating pain and needed help. A few more questions, she said. She needed the complete registration.
I was wheeled to radiology and sat in a hallway for what felt like forever, groaning in pain. I couldn’t find a comfortable position. Six or seven people walked by – and as they heard me groan, they would look down and walk faster. The x-ray technologist avoided eye contact. It was hard — I was right outside her room. Finally, I asked a passerby if she could help. Caught by surprise (I must have sounded human), she stopped. She looked at me. She then went into the x-ray suite. A few minutes later, a second technologist came out, saw my arm, and was the first to acknowledge that my arm looked painful. He told me the ER was pretty quiet and he would get me in right away.
Currently, India spends about $20 per person per year on healthcare and spending more once seemed like a peripheral concern, taking a back seat to basics like food and sanitation. However, in the past decade, as the Indian economy has grown and wealth followed, Indians are increasingly demanding access to “high quality” healthcare. But what does “high quality” mean for a country where a large proportion of the population still goes hungry? Where access to sanitation is so spotty that the Supreme Court recently had to decree that every school should have a toilet? What is “high quality” in a setting where so many basics have not been met?
It turns out that “high quality” may mean quite a lot, especially for the poor. A few weeks ago I spent time in Delhi, meeting with the leadership of the Indian health ministry. I talked to directors of new public medical schools and hospitals opening up around the country and I met with clinicians and healthcare administrators at both private and public hospitals. An agenda focused on quality rang true with them in a way that surprised me.
The broad consensus among global health policy experts is that countries like India should focus on improving “access” to healthcare while high income countries can afford to focus on the “quality” of that care. The argument goes that when the population doesn’t have access to basic healthcare, you don’t have the luxury to focus on quality. This distinction between access and quality never made sense to me. When I was a kid in Madhubani, a small town in in the poor state of Bihar, I remember the widespread impressions of our community hospital. It was a state-run institution that my uncle, a physician, once described as a place where “you dare not go, because no one comes out alive”.