The Health Care Blog – Page 458 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Why Health Outcomes Data Should Directly Feed Back To The Frontline

Oct 6, 2014• 3

By JOSHUA LIU, MD

The first time I met one of my staff physicians on Internal Medicine, he told our team he had just one rule:

“Our team must contact the patient’s family physician during the admission, inform him or her of the situation and plan for appropriate patient follow up after discharge.”

If you talk to any hospital physician or family doctor, they would almost certainly agree that this type of integration between hospital and community is essential for reducing avoidable ER visits, readmissions and improving other key health outcomes. Put more simply, it’s just good care.

And so you would think contacting a patient’s family doctor during a hospital admission would be the standard of care – but it’s not. There’s no rule or expectation; rather, it’s just something nice to do.

I’m not here to criticize health care providers who do or don’t act a certain way. I’m sure there are many best practices which some providers do that others don’t, and vice versa.

That said, I don’t think we can deny the harsh truth: It’s no longer about knowing what needs to be done to provide higher quality of care at a lower cost. We know enough answers to begin implementing.

Hospital at Center of Ebola Outbreak Reverses Its Story

Oct 6, 2014• 19

By THCBist

The Dallas hospital at the center of the Texas Ebola outbreak has changed its story.

Last Thursday, the hospital blamed a poorly designed electronic medical record for the failure to diagnose Duncan when he arrived at the hospital’s emergency room with symptoms consistent with Ebola, including a fever, stomach cramps and headache. According to the initial story, a badly designed electronic health record workflow made it difficult for doctors to see details of Duncan’s West African travel. Duncan was sent home. Very bad things happened as a result, as we all know by now.

On Friday, the hospital reversed itself without explanation.

The new statement:

Clarification: We would like to clarify a point made in the statement released earlier in the week. As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event. [ Full text ]

In other words: The EMR didn’t do it.

When the EMR story came out Thursday, critics jumped all over it. It did sort of make sense to some people, especially people who aren’t fans of electronic medical records. The idea that a piece of key information could get lost in the maze of screens and pop ups and clicks in a complex medical record sounded plausible.

A lot of other people weren’t buying it:

The swiftness of the hasty retreat led some critics to speculate that Texas Health’s statement Thursday provoked the wrath of EPIC, the hospital’s EMR vendor. Industry critics pointed out that many major EMR vendors, EPIC among them, often include strongly worded clauses in contracts that forbids customers from talking publicly about their products.

After this story was posted, EPIC contacted THCB with a response via email. Company spokesman Shawn Kieseau wrote:

We have no gag clauses in our contracts. We had no legal input or participation in our root cause analysis discussions with Texas Health staff on this issue. Texas Health’s correction is appropriate given the facts in this situation.

Would Clinical Decision Support Have Helped Prevent the Ebola Misdiagnosis?

Oct 5, 2014• 14

ART PAPIER, MD

Thirteen years ago, in the midst of widespread publicity about anthrax-laden letters poisoning people, emergency room physicians sent a postal worker home with a diagnosis of the flu. He later died from anthrax inhalation.

Fast forward to 2014, with the Ebola outbreak in Liberia dominating healthcare coverage, a man who had just returned from the stricken nation visited an emergency room with symptoms but was not tested for Ebola. He was sent home with antibiotics.

Two days later, he was diagnosed with Ebola. In the intervening days, he potentially exposed family members and many more to the deadly virus. At the hospital where the misdiagnosis occurred, officials acknowledged the doctors had the information about the patient’s recent travel in Liberia but didn’t act on it..

How can this continue to happen? In 2010, the Institute of Medicine (IOM) examined the threat of bioterrorism and infectious disease outbreaks and said the most “crucial step in disease detection is the first one – recognizing that an ill patient has a potentially unusual disease…” But it recognized the potential for misdiagnoses of diseases physicians rarely see – such as Ebola and anthrax poisoning – especially in busy emergency departments where information can get lost or overlooked.

The IOM recommended the use of clinical decision support tools to ensure doctors quickly and accurately detect and diagnose unusual diseases. Four years later, some hospitals have these tools and use them. But most do not, even though they’re readily available, affordable and proven effective.

An Extremely Teachable Moment

Oct 5, 2014• 5

JOHN MANDROLA, MD

It was a mistake to send the Liberian national Thomas Eric Duncan home from a Dallas emergency room after he presented with fever and pain, which were early signs of Ebola infection.

It would be a larger mistake to miss an important learning opportunity. This case demonstrates what I believe to be a major threat to patient safety—caregiver distraction.

Doctors and nurses are increasingly prevented from giving full attention to the important things in patient care. The degree of value-added nonsense has reached the point where delivering basic care has gown dangerous. This morning, in Canada, news of a case of deadly drug interaction occurred because of alert fatigue—or distraction.

I am a cardiologist; I am also a patient. I want the Duncan case to be a turning point, a wake up call, a never event that serves as a spark to improve the delivery of medical care. Right now, all that this case has changed are tweaks to EHR protocols and checklists. We need more than tweaks; we need big changes.

An uncomfortable truth is that medical mistakes are normal. Errors, like this one in Texas, have occurred since doctors started treating patients. The good news is that technology has made medical care better. No credible person suggests a return to the paper-chart era. Yet, it is still our duty to face mistakes, learn from them, and in so doing, improve future care. Being honest about root causes is necessary.

Another truth about medical mistakes is the ensuing rush to inoculate against blame–which always comes. In the Duncan case, initial blame was assigned to the electronic health record. The computer software failed to flag the travel history in the physician “workflow.” (Just using the word, workflow, hints of the bureaucracy problem.) And you know there is trouble when hospital administrators use the passive voice. “Protocols were followed by both the physician and the nurse…”

A Deeper Dive into the Rio Grande Valley

Oct 4, 2014• 8

FARZAD MOSTASHARI, MD

Last week, Dr. Bob Kocher and I took to the pages of the New York Times to detail a health care success story in Southern Texas. In a region once featured for its extreme health care costs and poor health outcomes, a group of physicians motivated by new incentives in the Affordable Care Act has started to change the equation. The Rio Grande Valley ACO Health Providers achieved eye-popping savings in their first year – coming in $20 million below its Medicare baseline and receiving reimbursements totaling over $11 million while also achieving better health outcomes for its patient population.

The savings number made for an impressive headline.

But as is often the case, other information had to be left on the cutting room floor. We dive a little deeper into the RGV ACO below:

The Central Role of Information Technology

Dr. Jose Pena, Chief Medical Director of the Rio Grande Valley ACO, emphasizes that one of the first and most difficult tasks for the newly-formed organization was developing an IT infrastructure that would serve their needs. “Using what was there wasn’t really an option,” says Dr. Pena, “so we built our own infrastructure.”

Forgoing a single EHR solution, the Rio Grande Valley now operates on a mix of cloud and office-based systems. The ACO developed software to identify metrics from various EHR systems, migrate that information to the cloud, and view real-time performance of providers. “IT accounted for 40% of our costs,” says Dr. Pena, “but the importance of proper reporting – to our leadership team, and to CMS – was at the top of our list.” The ACO identifies its customized IT system as foundational to its success.

3 Reasons Why Healthcare Needs Hackathons

Oct 3, 2014

AMAN BHANDARI and SACHIN JAIN

Medicine and public health have had a long history and strong roots in experimentation and solving problems through iteration. As healthcare now begins to intersect with tech like never before, the health focused hackathon offers an unprecedented opportunity for us to embrace this past while giving a home to the tinkering, experimentation, and solution-building that is needed now more than ever in our industry.

The first recorded use of the word “hack” occurred 900 years ago, but the more common and positive use of “hack”—to write a computer program for enjoyment—originated in the hallowed halls of MIT in the 1950s. The “hackathon, a portmanteau of ‘hack’ and ‘marathon’,” was first born out of a challenge posed to programmers at a conference in Silicon Valley by John Gage of Sun Microsystems in 1999.

Borrowing from what became a tech sector institution, one of the first health focused hackathons was launched at a national scale over a decade later in 2010 as a part of a public-private partnership between the US Government and Health 2.0 (co-launched by Aman Bhandari and Indu Subaiya as the Health2.0 Developer Challenge).

Since that time, the practice has expanded rapidly: we have found and analyzed over 100 health-focused hackathons (the full living database is available for download, analysis and editing on the MIT Hacking Medicine website here:

Can Pot Protect the Brain After Injury? A New Study Says It Can

Oct 3, 2014• 5

DAVID PLURAD, MD

The use of marijuana is associated with a marked increase in the risk of being involved in severe trauma particularly motor vehicle collisions. In 2009, for instance, marijuana use was a contributing factor in more than 460,000 emergency department visits in the United States.

But we also know that cannabis is potentially neuroprotective. Previous studies have found that tetrahydrocannabinol (THC), the active ingredient in marijuana, may have beneficial effects in certain types of neurodegenerative processes, like Alzheimer’s and Huntington’s disease. In addition, previous studies indicate THC may protect the brain in animal models of neurologic injury. However, clinical trials of a synthetic THC derivative were not ultimately associated with an increase in survival in patients with traumatic brain injury. Since overall findings were mixed, we hypothesized that use of the “native” form of THC could be associated with an increase in survival in patients with traumatic brain injury.

Wait, Maybe Technology Won’t Replace Doctors After All!

Oct 2, 2014• 11

LISA SUENNEN

Such a good question from my friend David Shaywitz, MD, PhD, (and co-author with me of the book Tech Tonics). David has spoken and written about this this theme frequently, and most recently at the Health 2.0 conference held last week in Santa Clara, CA. He and I and 2000 of our closest friends were there to talk healthcare technology. Isn’t it ironic that it takes that level of human interaction to talk about the ways healthcare can disintermediate humans from healthcare?

What struck me so loudly at the conference was how easy it is for us all to forget how human the healthcare experience really is. I moderated and attended numerous sessions at the conference, each a twist on the theme of how technology can make healthcare delivery more accurate, more efficient, more effective than anything we have going today.

David participated in a session withMatthew Holt, Vinod Khosla and Dr. Jordan Shlain, who could not be farther part from each other on the topic of doctor vs. machine (David played the role of moderate guy in the middle), Mr. Khosla backed away or at least clarified his earlier statements about how 80% of doctors will be unnecessary in the coming new age of healthcare technology. His revision was that 80% of alldiagnosis will, in the future, be done by computers, not doctors, because computers are far better at seeing a holistic view of a patient and taking in all of the relevant data. He talked about how certain digital technologies can know everything about you, including when you are sleeping and when you are awake. It made me think that Santa Claus must be worried about being replaced by an app.

Innovation, Primary Care Style

Oct 2, 2014• 7

DAVID HARLOW

On a recent evening at Harvard Medical School, the Primary Care Innovation Challenge and Pitch-Off ,sponsored by WellPoint’s American Resident Project, brought together six finalists, primary care luminaries and trainees, and a host of hangers-on and camp followers for a couple of hours of demos and discussions. The tenor of the evening, which was in many ways a pep rally for primary care – not that there’s anything wrong with that — was best captured by the rhetorical question posed by Asaf Bitton to the primary care practitioners and trainees in the hall, “Are you going to be a playwright or a critic?”

The hoots and hollers in response made clear that these are not your grandfather’s primary care docs. The call to action was echoed by many of the speakers, notably community organizer turned primary care physician Andrew Morris Singer and Dennis Dimitri, both advocating for, well, advocating for primary care. Bitton’s opening also included the exhortation that proved to be predictive of the winner of the top honors from among the six pitches: Innovation in primary care is not about the technology; it needs to enable better human care.

The Kaiser Permanente Model and Health Reform’s Unfinished Business

Oct 1, 2014• 20

By JEFF GOLDSMITH

For decades, health policymakers considered Kaiser Permanente the lode star of delivery system reform. Yet by the end of 1999, the nation’s oldest and largest group model HMO had experienced almost three years of significant operating losses, the first in the plan’s history. It was struggling to implement a functional electronic health record, and had a reputation for inconsistent customer service. But most seriously, it faced deep divisions between management and the leadership of its powerful Permanente Federation, which represents Kaiser’s more than 17,000 physicians, over both strategic direction and operations of the plan.

Against this backdrop, Kaiser surprised the health plan community by announcing in March 2002 the selection of a non-physician, George Halvorson, as its new CEO. Halvorson had spent most of his career in the Twin Cities, most recently as CEO of HealthPartners, a successful mixed model health plan. Halvorson’s reputation was as a product innovator; he not only developed a prototype of the consumer-directed health plan in the mid-1990’s, but also population health improvement objectives for its membership, both firsts in the industry.