New study: “harm to patients resulting from medical care was common”

The healthcare webs are buzzing with the results of a new study by Landrigan and cohort from the November 25 issue of the New England Journal of Medicine (read it here). The medical establishment is understandably never eager to see studies in prominent journals highlighting the dark side of medicine, where mistakes result in increased morbidity and mortality, ethical controversies (when to admit mistakes?), legal hassles, and resulting increased overhead at a level that would give Croesus pause. Of course problems are opportunities, and an army of specialists and managers have done a brisk business in recent years working on improving the situation. Doing well by doing good, perhaps? Researchers are getting interested as well: the relatively new field of medical cognitive science is making efforts to help hospitals cut down on errors. But when a study focuses on the lack of improvement in adverse event statistics after years of targeted investments, certain big-shots may be getting nervous. The Landrigan paper implicitly calls into question what return on investment patients and taxpayers are getting relative to the tremendous sums spent on quality assurance, risk management, error control, continuous improvement of safety, and so forth. The authors are careful to note that they sampled from a specific geographical region, and that in any event efforts to reduce adverse events from care should continue. Nonetheless:

In conclusion, harm to patients resulting from medical care was common in North Carolina, and the rate of harm did not appear to decrease significantly during a 6-year period ending in December 2007, despite substantial national attention and allocation of resources to improve the safety of care. Since North Carolina has been a leader in efforts to improve safety, a lack of improvement in this state suggests that further improvement is also needed at the national level.

And this:

In a statewide study of 10 North Carolina hospitals, we found that harm resulting from medical care was common, with little evidence that the rate of harm had decreased substantially over a 6-year period ending in December 2007. Although there was a modest reduction in the rate of preventable harms on the basis of external reviews, the reduction did not reach statistical significance in adjusted analyses. This apparent reduction was not substantiated by the internal reviews, which by all measures were of higher quality than the external reviews (i.e., higher within-team reliability at both primary and secondary review stages and higher agreement with experienced reviewers).

Our findings validate concern raised by patient-safety experts in the United States and Europe that harm resulting from medical care remains very common. Though disappointing, the absence of apparent improvement is not entirely surprising. Despite substantial resource allocation and efforts to draw attention to the patient-safety epidemic on the part of government agencies, health care regulators, and private organizations, the penetration of evidence-based safety practices has been quite modest. For example, only 1.5% of hospitals in the United States have implemented a comprehensive system of electronic medical records, and only 9.1% have even basic electronic record keeping in place; only 17% have computerized provider order entry. Physicians-in-training and nurses alike routinely work hours in excess of those proven to be safe. Compliance with even simple interventions such as hand washing is poor in many centers.

 

 

A poll on adoption of EHR’s

We are at the stage now where Federal writ must be interpreted and scrutinized by those planning budgets and personnel decisions. Institutions and organizations such as Regional Extension Centers face serious financial and logistical challenges concerning EHR’s. While these challenges certainly present opportunities for those of us in the healthcare informatics/healthcare IT world, the history of implementing complex upgrades to institutions that must provide mission-critical services during the upgrade is daunting. Healthcare CIO’s and CTO’s and directors must proceed with caution as the Feds operationalize the logistics of the ARRA EHR meaningful use provisions.

Houston Neal from www.softwareadvice.com/ passed along a note that they are running a poll on an important issue concerning the adoption of EHR’s and how the Feds are structuring incentives to do so.

One of the major components of the the American Recovery and Reinvestment Act of 2009 (ARRA) was the allocation of $19 billion to jump start the adoption of electronic health records (EHRs). One of the major uses of those funds was the establishment of Regional Extension Centers (RECs) to support EHR adoption by primary care physicians.

The entity spearheading this effort, the Office of the National Coordinator for Health IT (ONC), is specifically charged with helping 100,000 priority primary care providers become “meaningful users” of EHRs in 24 months. Eight months have passed since the ONC began funding RECs, and we’re skeptical that they will deliver.

Don’t get us wrong. We’re big advocates of EHRs. We’re glad to see such an energized EHR market. We’re just skeptical that throwing money at the problem will lead to efficient and successful adoption of this important technology.

In our opinion, there are five fundamental flaws with RECs:

1 Doctor’s aren’t moving as fast as the money is flowing
2 The market already delivers on what RECs promise
3 “Preferred vendor lists” limit choice and free markets
4 RECs won’t get doctors to “meaningful use” fast enough
5 The REC model leads to under-staffed, ephemeral entities“

What do you think about how electronic health records (EHRs) will be imlemented in the key category of Regional Extension Centers ? Take the poll at : http://www.softwareadvice.com/articles/medical/five-reasons-we-think-recs-are-reckless-1092310/#survey#ixzz10rpWUNdV

will evidence-based medicine shift hospitals to accountable-care organizations?

from http://www.dallasnews.com/sharedcontent/dws/bus/stories/112909dnbusbaylor.3d5ccc5.html

In an accountable-care organization, doctors and hospitals share a financial incentive to control costs and improve quality by coordinating care for a defined patient group.

Today, most medical care in Dallas and across the nation is delivered piecemeal. Doctors are paid for each patient visit. Hospitals are paid for each procedure. This “fee-for-service” model rewards caregivers for how much they do rather than how well they do it.

Health economists say it does too little to ensure that the people treating a patient know what’s been done by other caregivers. Too often, the result is duplication, waste and mistakes that are both expensive and dangerous to a patient’s health.

But what sounds like a commonsense approach is full of complications. Accountable care relies on a single, bundled payment that’s spread across all caregivers dealing with a patient. In its model, Baylor, with a powerful hold on much of the North Texas hospital industry, will decide how patients should be treated and how the payment pie is sliced. Doctors, hospitals and insurers in North Texas have a hard time trusting each other. And medical professionals don’t like being told how to do their jobs.

Patients may not like it either. The last overhaul of patient care and payments on this scale took place in the 1990s, when HMOs, or health maintenance organizations, were introduced on a wide scale. Patients rebelled against insurers getting between them and their doctors on decisions about care, and they may not see much difference if it’s a hospital rather than an insurance company making the calls under accountable-care.

In 2000, 3 million Texans were enrolled in HMOs. Last year, it was 852,000.

In that decade, however, Dallas changed from an average spender for health care to one of the biggest spenders in America on a per-patient basis.

Congressional Democrats have struggled for months to write legislation that will extend coverage to more Americans, including many in Dallas who lack health insurance. Insurance might persuade some of those people to seek preventive treatments they now skip because of cost. The legislation also encourages communities to try models such as accountable-care organizations, under the theory that doing so will lead to better care at lower cost.

“I don’t think we can really afford to wait for what might happen with national health care legislation,” said health economist Mark McClellan, keynote speaker for Monday’s summit.

“It’s very clear we need to move to more preventive care, and more coordinated care. While legislation can help address that, there are certainly a lot of steps that can be taken in the meanwhile, ahead of health care reform.”

Wooing employers

Roberts said Baylor will not wait for Congress to pass a health care overhaul bill. Instead, he has been going directly to large North Texas employers with a pitch that Baylor can improve quality while lowering costs with an accountable-care model.

“I might go to a Texas Instruments and say, ‘I know you’ve been struggling with your health care costs. Can we help you bend the cost curve?’ ” Roberts said.

Early next year, Baylor will meet with the Texas Employees Retirement System and Blue Cross Blue Shield of Texas to see if it can help slow the growth of the system’s health care costs.

Those costs for the 528,000 participants are projected to be $2.1 billion by year’s end, according to the system’s records.

“We will be looking at a number of innovations in plan design and reimbursement structure, including patient-centered medical homes, clinical integration and an accountable-care organization structure,” Roberts said.

In Baylor’s accountable-care plan, Baylor would be held responsible for organizing its hospitals and physicians to lower costs. In a contract, the employer would have to agree to a number of terms, possibly changing health insurance plans, which could set up fights between Baylor and health insurers. The contract might also require the employer to hire an outside wellness program developer to get workers in shape, Roberts said.

What’s less clear, and more controversial, is whether employers would instruct workers to visit only Baylor doctors and hospitals.

Roberts said he’s unsure what employers will do. If employees are given the freedom to choose their doctors and decide not to participate in Baylor’s accountable-care system, then Baylor has limited power in controlling costs.

If workers are limited to Baylor services, the hospital system secures a steady revenue stream and leverage over regional hospital competitors.

One difficulty facing health providers that are considering accountable-care models is how to sell the idea to patients without their feeling it’s just another cost-control measure.

“The challenge with evidence-based treatment is that sometimes we don’t like what the evidence shows,” said Eduardo Sanchez, chief medical officer of Blue Cross Blue Shield of Texas. Sanchez pointed to the uproar over a federal advisory panel’s recommendations that women younger than 50 don’t need routine annual mammograms screening for breast cancer. The panel warned that early testing causes many more false diagnoses and needless procedures than life-saving cancer detections.

“Does preventive medicine have to save money to be worthwhile?” Sanchez asked. “The response has been that, clearly, it shouldn’t be driven by the idea of saving money.”

What do tomorrow’s physicians think about trends in health care?

4 questions for: Megan Gray, MD/MPH Candidate 2011

1-What do you think is driving up health care costs so much?

1) Insurance companies- the very nature of inserting a middleman creates often unnecessary jobs, time, and paperwork. compare the example of Ontario’s 900-bed general hospital with Mass Gen’s 900-bed hospital… Ontario has 3 people in the billing department, while Mass Gen has 300… so really it’s a bunch of kind of false jobs created that are taking up resources.  For-profit insurance companies also drive up health care costs, as well as pharma companies that claim to increase costs to pay for R&D, but really spend too much on marketing/pushing drugs to doctors.

And if you want to get philosophical, Americans aren’t used to a patriarchal healthcare system… but this seems to work well in other developed nations.  Americans would probably do better with less choice for insurance plans… although Germans have 240 “sickness funds” to choose from.

2-Dr. David Brailer, former national coordinator for health information technology in the Bush administration, in evaluating Wal-Mart’s upcoming Electronic Health Records plan, states that “If Wal-Mart is successful, this could be a game-changer” (see http://healthcareinformaticsblog.wordpress.com/2009/03/11/wal-marts-electronic-health-record-plan-could-be-a-game-changer/) Do you agree?

Wal-Mart would absolutely be a game changer- I noticed how freaked out physicians got over losing some autonomy to Wal-Mart’s hugely successful in-store clinics when they started, run mostly by nurse practitioners… a lot of the recent TMA (ed. note: refers to Texas Medical Association) discussions have been about limiting these types of clinics… Wal-Mart is enormously savvy in the healthcare sector and in that respect, proved they knew their clients… so with the EHR endeavor, they’re again proving they know their clients- just about every small town has access to a Wal-Mart, so small town/suburban doctors can easily access the system from a source/name they trust, with a store presence in case they need assistance… rather than a traveling IT salesperson coming into their office and then retreating to headquarters back in Dallas or New York… so yes, Wal-Mart plays a huge role in the industry.

3-When all the smoke is cleared from the policy battles over the level of access the insurance industry will have to patient EHR/EMR, do you think there will be more, not less, successful denial of coverage for policyholders by the insurance companies, based on data-mining for evidence of patient pre-existing conditions? Is the HIPAA Privacy Rule adequate to protect patient privacy?

I would think less since the nature of EHR allows for more standardization of practices/commonalities across patient cases, and a better electronic trail to document just why a claim was denied.

Another point: insurance companies might be wary of too much data mining, in case of a public backlash and an industry shift to phase them out so as not to worry of data mining at all… if we expanded a national system like Medicare to cover everybody, pre-existing conditions would cease to exist at all…as a greater risk pool would decrease the cost to insure any one member.

4-Where are the low-hanging fruit in the healthcare system that could keep costs from rising further, if any?

I really think that moving to an EHR system would help us contain costs better… not exactly low-hanging, but inevitable… and all the medical students I talk to can’t imagine using paper records in their careers, after having grown up with info so readily accessible online.  Hopefully in the next few years it will take to implement such a system, the 60-65 year old bracket of old school anti-EHR docs will be on their way out…

A lso, practicing defensive medicine grossly exaggerates our use of labs/tests… for example, in Britain, doctors come up with the most likely diagnosis and begin to treat that… if there is no resolution, they move on to what’s next most likely on their differential diagnosis list. here in the U.S., docs are so fearful of litigation that they must order CTs and MRIs and extra labs from the outset just for the rule/out… for it’s better to spend a couple hundred extra now than risk thousands of dollars if you don’t seek out extra problems.

Also, pharma drugs- I wish there could be some type of legislation to limit the amount of marketing $ each company could spend… a national healthcare plan could also negotiate better bulk rates on drugs, similar to the dirt-cheap rate the VA gets now… I know lots of people who get prescriptions from Canada because the exact same drugs are literally 1/2 the price…

(in the interests of full disclosure, the repsondent is a family member)

Uwe E. Reinhardt: healthcare comparative effectiveness analysis and cost-effectiveness analysis

from http://economix.blogs.nytimes.com/2009/03/13/cost-effectiveness-analysis-and-us-health-care/

With so much brouhaha over what should be thought of as basic operations research for health care, it may be well to explore what “comparative effectiveness analysis” is, and how it is related to what is known as “cost-effectiveness analysis.”

The sketch below describes the basic structure of “comparative effectiveness analysis.”

It is assumed that researchers compare two therapies aimed at the same medical condition. The researchers try to determine which of these therapies can be judged “better” in terms of the positive and negative consequences associated with them. In principle, the clinical practice guidelines promulgated by medical specialty societies to help physicians with their daily treatment decisions should be based on this type of carefully structured comparative effectiveness research.

Source: Uwe Reinhardt A diagram of comparative effectiveness analysis.

Alas, in practice most of the currently promulgated guidelines lack that kind of rigorous scientific foundation. For example, as the science reporter Ronald Winslow recently reported in The Wall Street Journal “just 11 percent of more than 2,700 recommendations approved by cardiologists for treating heart patients are supported by high-quality scientific testing, according to new research.”

That circumstance alone justifies spending billions more than we traditionally have on operations research for an industry that now absorbs $2.5 trillion or close to 17 percent of our gross domestic product. Why anyone would oppose that kind of research challenges one’s imagination.

Early drafts of the economic stimulus bill, however, referred not only to “comparative effectiveness research,” which keeps the analysis strictly in the clinical realm, but also to “comparative cost-effectiveness analysis,” which brings economics into the inquiry. That analysis seeks to establish which of several alternative therapeutic strategies capable of achieving a given therapeutic goal is the least-cost strategy. It seems a sensible form of inquiry in a nation that is dismayed over the rising cost of its health care.

Indeed, in recent years most industrialized nations have begun to subject clinical practices in their health systems to this type of analysis, as have private insurers in the United States (see, for example, the American Journal of Managed Care).

In Congress, however, the word “cost” in this connection remains anathema. This is despite the fact that that same Congress rings its hands in despair over the millions of American families priced out by the ever-rising cost of health care, and over the bigger chunk of the federal budget taken up by Medicare and Medicare.

So, in the end, the offensive term “cost-effectiveness analysis” was stricken from the bill.

The opposition to cost-effectiveness analysis in health care comes from two distinct groups that work closely together and reinforce one another.

The first group includes individuals or enterprises that book other people’s health-care spending as their own health-care income.

The manufacturers of pharmaceutical and biotechnology products or of medical devices are often found in that group, even though in some instances the greater economic transparency provided by cost-effectiveness analysis might help them market their health products or health services. Also in this group are physicians who thrive economically from highly resource-intensive medical treatments, even if some of its components are of only marginal clinical benefit.

The second group among the opponents of cost-effectiveness analysis includes individuals who sincerely believe that health and life are “priceless” — for them, cost should never be allowed to enter clinical decisions. It is an utterly romantic notion and, if I may say so, also an utterly a silly one. No society could ever act consistently on such a credo.

Ephraim Schwartz: Financial and technology issues make Obama’s EHR push not so easy to execute

from www.infoworld.com/article/09/03/11/10FE-electronic-medical-records_1.html

Up until now, the benefits of electronic medical records that have occurred accrue to just about everybody — patients, employers, state and federal governments, and medical insurers — but the actual health care providers. Doctors get the least benefits, especially in small practice groups (those with fewer than five physicians) that make up most medical practices.

But even those who might benefit from electronic health records don’t, says Homer Chin, associate medical director for clinical information systems at Kaiser Permanente Northwest. Why? Because there is little incentive to share information, the core of an electronic health record (EHR; also called an EMR for “electronic medical record”). For example, hospitals make money by doing tests. But once EHRs are up and running, a doctor ordering a test electronically might immediately receive an alert saying the test was unnecessary because the patient had the same test or procedure at another location. “There is not much revenue and profitability in putting in an EHR. There is little financial incentive,” Chin says.

An ironic consequence of EHRs is that, by helping raise the quality of health care, they penalize doctors and other medical providers for success, says Wes Rischel, a vice president at Gartner. The bottom line: Doctors will see fewer patients.

Beyond the income factor, the high cost of EHR systems today — not only the systems, but the setup and training — also dissuades adoption by doctors, especially those in small groups. Physicians have been unwilling to invest anywhere from $20,000 to $50,000 in an EHR system where the economic benefits tend to go to someone else. Today’s EHR systems are not as easy to use as they could be, so there is a large learning curve required, Chin says: “There is something intuitive about paper chart and prescription pad.”

Recognizing these factors, the stimulus package tackles these financial challenges head on by offering money to health care providers. Hospitals submitting via EHR systems to Medicare and Medicaid will receive up to $6 million a year in additional payments for sending data electronically. This incentive will remove much of the adoption inertia seen so far, says Richard Archer, a principal in the health care IT advisory practice a KPMG.

<snip>

But now Microsoft, Google, and AOL founder Steve Case’s Revolution Health are looking at entering the health care information exchange market. All three offer individuals a personal health record, which puts the patient in control of his medical information. But the business aspect is in giving health care providers access to a person’s complete health record from a single site.

There are two major questions around the reliance on health records from these providers, say industry analysts. One is whether users will trust a for-profit organization to care for the most personal kind of information. The second is whether each of us can be trusted to manage and keep such a life-and-death record up to date or if it’s safer to leave that responsibility to organizations whose only job it is to keep the health data updated.

The prognosis for EHRs
EHR providers are, not surprisingly, bullish on the future of EHR efforts. Greg Mancusi-Ungaro, a senior director at Exigen Systems, says deploying an EHR system is just like implementing any big enterprise application, only the enterprise in this case is bigger and the stakes are higher. “The technology exists today and despite the fact that we lack some core standards, we are enabling the development of a flexible infrastructure to stay in tune with requirements. I can visualize a successful national system,” he says.

As Kaiser’s Chin points out, there is a convergence occurring around health care technology regarding how to share it and use it to assist delivery of services and treatment. But the challenge of orchestrating and satisfying so many stakeholders remains. Plus, even if the solutions are mandated rather than eventually negotiated, the task of gathering the many pieces that are still in flux, then integrating them remains a complex technical and process task.

Over time, both industry representatives and analysts expect that every U.S. citizen will have an EHR available nationwide. But to make it happen will require a great deal of cooperation, innovation, and an investment in health-oriented IT. This shift will likely start at a less ambitious level than the political rhetoric suggests, with local practitioners sharing patient information in a local health care ecosystem.

Weekly Healthcare Reform Update from Healthcare Information and Management Systems Society

Healthcare Reform Update – This Week’s View From Washington, D.C.

from  www.himss.org/ASP/ContentRedirector.asp?ContentID=69003&type=HIMSSNewsItem

Originally, it was estimated that $19.2 billion in health IT was included in ARRA ($2 billion for the Office of the National Coordinator and $17.2 billion for incentives through Medicare and Medicaid).

The Congressional Budget Office (CBO) now indicates that approximately $23 billion is included for health IT through the legislation ($2 billion for the Office of the National Coordinator and $20.819 billion for incentives through Medicare and Medicaid). A new CBO report estimates that enacting the ARRA legislation would increase federal budget deficits by $787 billion over the 2009 – 2019 period. ARRA authorizes and appropriates $2 billion for the Office of the National Coordinator for Health IT. Of the $2 billion, the CBO projects that $300 million will be spent in fiscal year 2009, $1.28 billion in fiscal year 2010, $360 million in fiscal year 2011, and $40 million in fiscal year 2012. (See page 5 of the PDF.) In addition, the CBO now estimates higher projections for eligible providers that demonstrate a meaningful use of certified EHR technology at a new net cost of $20.819 billion. $20.819 is derived from the sum of the total costs of the incentives in fiscal year 2009 – fiscal year 2015 ($36.368 billion) and the total savings that are achieved in fiscal year 2016 – fiscal year 2019 through the incentives ($15.549 billion).