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Tag: Quality

QUALITY/PHYSICIANS: When war is declared it’s hard to find a middle way

In Friday’s NY Times there’s an article called In Texas, Hire a Lawyer, Forget About a Doctor?. The article features a database online called DoctorsKnow which allows doctors (for a fee of course!) to find out which of their patients has sued any doctor. The logical conclusion to this is that anyone who has ever sued a doctor cannot get any care. As this behavior starts up for real rather than just as a philosophical debate in Medrants, it strikes me that we are getting to the point at which war is starting. Many doctors might say that the trial lawyers have already been at war with them and they’re just responding. Most of you know that I’m on the physicians’ side in this battle, but believe that averting the war is a much more desirable outcome than fighting it (which reminds me of the Iraq situation!).

Matt Quinn, who some of you may suspect is on the lawyers’ side captures my feelings in this note:

    This article speaks to the need for someone to be a moderating force in this debate: of course, all trial lawyers aren’t bad, all doctors aren’t bad, and all people who sue for malpractice aren’t bad. Perhaps the government (CMS?, AHRQ?, ???) could convene the AMA, ATLA and other entities to come together to propose a centrist solution that provides justice for all. That would require both of those organizations to set aside some of the immediate narrow self-interests of their memberships and work together for a sustainable solution that solves the problem – something that would benefit all stakeholders involved, including (last but not least) the thousands of people who are harmed each year by malpractice. Not likely in an election year.

Unfortunately Matt’s right. While this fight get politicized it cannot be changed into a sensible peace settlement. Unless of course organized medicine breaks away from the mainstream "tort-reform" movement that’s really a part of corporate America wanting to pursue unmitigated bad behavior, and proposes a different tack in cooperation with moderate voices for sanity in medicine like the IOM.

QUALITY: Matt Quinn on why we “need” malpractice litigation

From the THCB Sacramento bureau, Matt Quinn chimes in on the “value” of malpractice litigation. Matt has been annoying the doctors over at DB’s Medical Rants (in these long, varied and interesting comments) by defending trial lawyers–which is a little akin to a Satanist wondering into a Catholic mass. Over here in the more rarefied air of THCB, I’ve been trying to suggest that there’s a middle path in the malpractice debate. But like Matt I don’t think that the AMA policy of just putting a $250,000 limit on pain and suffering awards does anything to solve the problem. Matt picks up on a tragic case in Sacramento, where apparently one hospital follows a stricter guideline than another, and it really made a big difference. Matt comments:

    In summary, a woman’s doctor recommends that she go to UC Davis Medical Center for a days-long diagnostic procedure to try to determine the source of the aberrant electrical activity in her brain. She would be taken off all medications, and a video camera trained on her during her stay would record any seizures and collect corresponding brain activity. The data might later enable a brain surgeon to remove the tissue causing the seizures. During the “monitoring” the woman has a seizure and dies. Her family finds her about an hour after she died. Experts say there are no standards – only guidelines from the National Association of Epilepsy Centers – for running video-EEG monitoring units.

    “There is no national standard requiring that a human being be observing every patient on video monitoring 24 hours a day,” said Dr. Robert Gumnit, a Minneapolis neurologist who pioneered the technology more than 30 years ago. “The reason is that the information is being gathered to learn about the electrical activity of the brain and the behavior of the patient during a seizure – and that is always analyzed the next day or some other time. It’s not being used to ensure patient safety.”

    Nevertheless, some centers do more than others in that regard. At Sutter General Hospital in Sacramento, for example, a specially trained technologist sits in front of a bank of large monitors – one for each of four beds – 24 hours a day. Each monitor shows the patient in the bed and displays the patient’s brain waves, blood oxygen levels and respiration rates.

    Such monitoring would have probably saved this woman (or at least alerted a nurse to respond). I wonder if this has ever happened before (why does Sutter have more stringent guidelines?). Why wouldn’t the National Assoc. of Epilepsy Centers commit to standards? It would certainly make assessing liability (to mention nothing of ensuring that no harm is done) much easier.

I’m not sure that we need malpractice litigation in this case (especially as a California taxpayer I’m picking up the defense’s tab), but something should be done to make sure that UC Davis Medical Center does much better in the future, and that guidelines/processes aren’t implemented so differently in the same town. And if it takes a lawsuit to do that? Well, surely we can do better.

QUALITY/CONSUMERISM: Treating patients like, well, people?

I’ve spent the last two days in a huge planning conference for Ascension Health, a Catholic multi-system (or multi-Ministry) chain that’s looking to transform its future. In fact they have a huge ongoing project they term their Call to Action and they have a system wide commitment to providing Health Care That’s Safe, that Works and that Leaves No One Behind. It’s a very ambitious program, and it’s great to see a provider system do something big and proactive. One arena that they are looking at transforming is their relations with consumers. I spent yesterday with a group of hospital marketing folks who essentially admitted that their organizations have not to this point made the patient experience their hospital’s central priority. And that is pretty typical of hospitals and providers across the country. For this system at least, that is going to change over the coming months and years.

This is not to say that the folks in the room don’t have shining examples of great patient-centered programs in their own facilities. One example is the Breast Cancer Center at St Agnes, Baltimore which provides a dedicated nurse to each patient to work as their advocate, and also puts together an immediate cross-specialty team to give each patient and their family the full range of information about available treatment choices. Longer-term observers of the health care scene may recall the experience of Andy Grove, then CEO of Intel, when as a newly diagnosed prostate cancer patient had to traipse around visiting multiple physicians, none of whom could give him accurate information about the relative likely outcomes of the procedures they offered.

Well as the WSJ’s Informed Patient column reported yesterday (sub req’d) there’s a new report out from a conference on Disease Management Outcomes sponsored by Johns Hopkins and American Healthways on the patient-physician relationship. Many of the informed consumer issues are reflected and it’s worth reading the full report. Here’s the executive summary/recommendations:


    1. All parties should acknowledge patients as most knowledgeable about their symptoms, and patient self-assessments should guide the nature and timing of both the physician’s response and of scheduled visits.

    2. Patients should recognize the importance of providing feedback for improving their care. Physicians and their offices should welcome patient feedback and establish safe ways that patients can provide it.

    3. Physicians should implement a social questionnaire as part of the initial intake, allowing the patient to communicate essential, non-medical information about their lives. This information should be integrated into ongoing care. Information captured on the social questionnaire should include: marital status and/or significant others, education and occupation, hobbies, religious preference, preferred methods of communication and the patient’s preferred level of involvement in health care decisions. Understanding what makes each patient unique can help personalize care and reduce the risk of misunderstanding, error or loss of rapport.

    4. Physicians and support staff must recognize the role of patients’ gender, age, race and religion in their treatment and ongoing care.

    5. Delivering traumatic news to the patient demands that physicians find an appropriate environment with adequate time and ample consideration for the concerns of the patient, family and/or advocate.

    6. Physicians must respect and incorporate the patient’s designated advocate into the care relationship. Patient advocates, caregivers and family members should be present when appropriate, so that their roles are integrated into the care plan from its outset. In recognizing the legitimate role of advocates and caregivers, physicians should be prepared to fully discuss (1) limitations imposed on their participation by privacy laws and other statutory and regulatory requirements and (2) how other legal instruments (such as durable powers of attorney, living wills and advance directives) may enhance their roles.

    7. Physicians are responsible for providing current, scientifically based “best medical practices” in an ethical and timely fashion. They should instruct patients on benefits and risks and inform them of all reasonable diagnostic and therapeutic options, even if an option isn’t covered by insurance or requires referral to another physician.

    8. Patients should seek–and physicians should promote–active, collaborative discussions with patients. They should take care to express medical information in laypersons’ terms to ensure full comprehension by patients. The
    stresses of illness can impair a patient’s ability to absorb details of the visit. Effective physicians summarize their recommendations and assess patients’ (and/or their advocates’) level of understanding, leaving time for additional
    clarification.

    9. The patient-physician relationship must mirror our daily lives by relying on methods of communication that are not limited to inflexible, one-on-one visits but may include e-mail and phone communication, disease management
    services, Internet access, written or verbal agreements, group visits and universal medical records that are accessible at the point of care.

    OUTCOMES
    The outcomes we expect from improving patient-physician communication include:
    –Improved patient adherence to recommended therapies
    –Improved patient self-care
    –Improved comprehension of information given by the physician
    –Increased patient satisfaction and more word-of-mouth referrals from happy, established patients to potential
    new patients
    –Increased physician satisfaction
    –Improved capacity for physicians to see patients as whole persons, rather than diseases or organ systems
    –Improved ability for patients to see physicians as people who also want and need mutually satisfying, therapeutic
    relationships and are doing their very best to help patients

By any stretch of the imagination this is an ambitious set of goals. But nothing on this list is impossible, and if it’s all implemented successfully, those outcomes (and they are not purely clinical outcomes) will be the reward. Of course, as the group I met with yesterday acknowledges, health care organizations need to make some big changes to accomplish these goals.

QUALITY QUICKIE: Interview with Robert Wacther

The San Francisco chronicle had a couple of interesting pieces that I read on the plane east this morning.  The first was an interview with Robert Wachter about his new book Internal Bleeding. He has a lot of sensible opinions that are mainstream in the Quality movement, but are yet to really make it into public consciousness.

The reason he’s getting good press is because the book tell stories.  A "fun" one is this about a physician’s poor hand writing causing a little problem. The prescription is reprinted in the book

    We asked 159 physicians to look at the handwritten prescription. Half thought it was for Plendil, a calcium channel-blocker; a third said Isordil, a longer-lasting version of nitroglycerine taken for angina; and others thought it was Zestril, a blood pressure medication. We reproduced the prescription in our book. … Take a look. What do you see?

    Plendil.

    Wachter: You would have killed the patient. The prescription was for Isordil, but the pharmacist thought it said Plendil. The daily dosage for Isordil is 80 milligrams; for Plendil, 10 milligrams. The pharmacist read Plendil, the patient took 80 milligrams. He had an eightfold overdose.

    (The patient, Ramon Vasquez, suffered a severe drop in blood pressure, and 24 hours after starting the regimen had a massive heart attack. He died several days later. A jury awarded his widow $450,000.)

Maybe if word gets around we might find some progress on the eRx issue, but recall that this case was in 1991 (or at least that’s what it said in the dead tree edition–edited for space in the electronic version).

QUALITY QUICKIE: Prescribing wrong drugs happens too often

A CDC study shows that one prescription in every twelve written for elderly patients is potentially dangerous. The full abstract is here while here’s the rather more user-friendly news release.  What’s somewheat depressing is that this is 2000 data and despite the IOM report and other news about, nothing had improved since 1995.  Hopefull it’ll be better by the time the study is done in 2005, with more attention to the issue and more electronic prescribing.

Ouch! Internal Bleeding exposes medical errors

Modern Physician has an interview with Bob Wachter, who’s new book is called Internal Bleeding. There are something in the region of 20 odd medical errors written up in the book, with a view to showing the system problems behind them.  This is something of an old story, and Michael Millenson’s Demanding Medical Excellence gave a great account of the overall safety/quality environment a few years back.  But the more the story can be told the better the chance that the battleship will be turned in the direction of safer medical care. In fact several large health organizations are actively working on these programs, such as Ascension’s Healthcare that’s safe.

QUALITY QUICKIE: EBM goes mainstream (sort of)

With a hat-tip to Lisa Williams, this month’s Atlantic Monthly Journal has the first article I’ve ever seen in a mainstream magazine on EBM. The author calls for a national clinical institute to supplant the NIH and AHCQ, and actually make pronouncements on what works, and try to get the medical profession and health care industry to follow it. I’m so knocked out by an article on this topic getting into a major non-health care journal, that it would churlish to point out that our British cousins have already got one.

INDUSTRY/QUALITY: Better Health Technologies DSM e-Newsletter

Just in case you haven’t seen it before take a look at the e-Newsletter from Better Health Technologies.  It’s written by a smart veteran of the DSM wars, Vince Kuraitis, and this month’s has a particularly fine analysis of recent studies on the cost-effectiveness of DSM.  The answers are, by the way, "Yes it works", "No it doesn’t", "Be careful out there", and "Just Do it Anyway", depending on who you believe. The most recent newsletter has Vince’s 7 Key Trends on DSM in 2004.  You can sign up here and the price is very good indeed.

QUALITY QUICKIE: Letter from England, (with UPDATE Tues)

UPDATE: Don Johnson and I are having a friendly spat about the real cost of health care in Europe and another about the uninsured in the new comments section of The Business Word.  I hope that Don keeps support for his comments section up and that you’ll join me in commenting there. (I’m barely able to keep my blogging up, so no comments here for a while yet).

I’ve been in the UK for a few days and thought that it would be appropriate to give you some impressions of what I’ve been hearing about the state of health care over here. One of the most noticeable factors is that we’re not in France. The BBC reported last night that the French health service was about to have a doctors’ and pharmacists’ strike because of threats to reduce government finance of the system there.  The BBC reported with some incredulity that any French person can get any operation they like any time for free, but did point out that the French pay 30% more overall for their system, and that (stop me if you’ve heard this tune before) costs were going up faster than the economy can afford it, etc, etc.

The UK is also increasing its rate of health expenditure from what used to be a very miserly 5.5% of GDP on the way to 7-ish%.  In some ways they are having capacity constraints, with the result that some GP positions in London are vacant, and some patients are being sent to France for surgery to reduce waiting lists.  That’s possible because these days funding for primary (including Rx) and secondary care is organized via Primary Care Trusts (PCTs) which buy (or "commission" in New Labour-speak) hospital services from Trust Hospitals.  Although this might seem like the basis of a competitive market, in fact a PCT tends to cover virtually all the residents of one town, and the hospitals they purchase from usually have a catchment area that’s about the same size as the PCT.  In other words there’s more or less a single buyer (that looks something like a staff-model HMO) and a single seller (the local tertiary care hospital) — and there’s not real money flowing between them. Within the PCTs, the primary care is delivered by notionally independent GP practices, who behave much as they always did — although the minority which were "fundholders" under the previous reform environment probably have less control over hospital purchasing than the used to.

The most interesting development is the move towards what might be called intermediate risk sharing for chronic disease management. Starting in April 2004, GP practices will be putting up to one third of their revenues at risk, and be able to earn 1050 points by hitting a number of targets in certain therapeutic areas.  Each point will start off being worth up to 75GBP but will go up to 120GBP.  In other words each GP may have up to 120,000 GBP at risk for their practice, which may wind up to 30-40,000 GBP per doctor in real money. There are ten chronic disease states being targeted, many of them surrounding cardiac care, with some 75 metrics being measured. The measurement of the interventions, which are all the standard things of keeping the heart patients on the right drugs, making sure the diabetics get their eye exams, etc, etc, are being done from the information systems of the GPs themselves.  But this isn’t the gong show it would be in the US as by now the vast majority of GP practices have got primary care EMRs, and most GPs are taking electronic notes during consultations.

To this point, many GPs have just been coding office visits with electronic diagnoses that are the easiest to input rather than the most accurate (i.e. coding all visits from diabetics the same).  They don’t get paid any differently for different codes (unlike the US) so convenience had been the driving factor. Most of the GPs I talked with are fairly confident that the add-ons required, such as alerts to contact patients to make sure they’ve come in for an annual exam, or alerts to remind the GP in the middle of the consult that the hypertensive patient hasn’t had a blood pressure test, can be (or already have been) added to their systems – and that’s where they’re focusing the most effort. There’s also a presumption that some of the smaller one or two doctor GP practices with only a couple of thousand patients will merge to get better IT IT and admin support. Overall there’s some optimism about the system, as reflected in this American assesment from UCLA’s Paul Shekelle.

It’s also interesting to note that in the absence of the completion of the huge EMR in the sky projects that the government just awarded contracts for, the UK is already far ahead of the US in primary care IT.  However, this doesn’t really spread over to the hospital side.  In fact frequently the communication between GP and Hospital specialist breaks down (does this sound familiar?) and a patient may be put on a drug in the hospital and the GP either not be informed about it, or take them off it when they come for the follow up visit. As the GPs currently control their own drug budget they’ve been somewhat incented to under-prescribe – any savings there can be used in the rest of the practice to buy new computers, nicer chairs for the waiting room, etc. Additionally the end points that GPs are going to be rewarded on are based on intermediate outcomes, not on hospital measures.  So for example, getting the % of at-risk patients on statins up above a certain number will be rewarded and it’s just assumed that this will reduce costs down the line and in the hospital.  But at present no one’s counting and the information systems aren’t really able to talk to each other about it. However within the PCTs there are already guidelines that many GPs (are at least trying to) follow willingly, even though they’re paper based, and there is a system of clinical consultation over local guidelines at the PCT level itself.  As well as the NICE (national institute for clinical excellence) which creates national guidelines for technology and drugs based on cost-effectiveness analysis.

Additionally there was great familiarity with the Kaiser system, and the NHS has done a series of comparisons between the two, which in part inspired the new contracting system by showing that the lower use of hospital care and greater emphasis on overall patient management at Kaiser led to better and more cost-effective care.  But many people I talked to were aghast when I described the state of IT in the typical American doctors office – they just assumed that the rich Yanks must be well ahead of them!

QUALIITY: Says here that Doctors read the news!

Over at DB’s Medical Rants Robert has responded  to my gentle chiding and has written a nice piece regarding what’s wrong (in his view) with Wampum’s piece on malpractice.  (Note that he got up at 4 am to write it too! Who’d be an intensive internist?)

He’s also alerted me (and you) to a very interesting report about how doctors changed their behavior after the results of the two big trials on HRT and Alpha Blockers in the last couple of years. (Reuters release here but both full articles are unusually available for free from JAMA via my earlier links). The findings suggest that doctors do indeed respond in their prescribing habits to the latest evidence, particularly if the results of the trial are blared all over the press. This just makes the whole conversation over evidence based medicine more and more confusing.  How come doctors change practice on a dime over the HRT study but take years and years to apply some of the best practices elsewhere . . . . . I think Robert’s deliberately trying to make my future article about this harder to write!

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