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My HIMSS will be all about quality and patient safety

As regular readers might already know, 2012 was a transformative year in my life, and mostly not in a good way. I ended the year on a high note, taking a character-building six-day, 400-mile bike tour through the mountains, desert and coastline of Southern California that brought rain, mud, cold, more climbing than my poor legs could ever hope to endure in the Midwest, some harrowing descents and even a hail storm. But the final leg from Oceanside to San Diego felt triumphant, like I was cruising down the Champs-Élysées during the last stage of the Tour de France, save the stop at the original Rubio’s fish taco stand about five miles from the finish.

But the months before that were difficult. My grandmother passed away at the end of November at the ripe old age of 93, but at least she lived a long, full life and got to see all of her grandchildren grow up. The worst part of 2012 was in April and May, when my father endured needless suffering in a poorly run hospital during his last month of life as he lost his courageous but futile battle with an insidious neurodegenerative disorder called multiple system atrophy, or MSA. (On a personal note, March is MSA Awareness Month, and I am raising fu nds for the newly renamed Multiple System Atrophy Coalition.)

That ordeal changed my whole perspective, as you may have noticed in my writing since then. No longer do I care about the financial machinations of healthcare such as electronic transactions, revenue-cycle management, the new HIPAA omnibus rule or reasons why healthcare facilities aren’t ready to switch to ICD-10 coding. Nor am I much interested in those who believe it’s more worthwhile to take the Medicare penalties starting in 2015 for not achieving “meaningful use” than to put the time and money into adopting electronic health records. I’m not interested in lists of “best hospitals” or “best doctors” based solely on reputation. I am sick of the excuses for why healthcare can’t fix its broken processes.

And don’t get me started on those opposed to reform because they somehow believe that the U.S. has the “best healthcare in the world.” We don’t. We simply have the most expensive, least efficient healthcare in the world, and it’s really dangerous in many cases.

No, I am dedicated to bringing news about efforts to improve patient safety and reduce medical errors. Yes, we need to bring costs down and increase access to care, too, but we can make a big dent on those fronts by creating incentives to do the right thing instead of doing the easy thing. Accountable care and bundled payments seem like they’re steps in the right direction, though the jury remains out. All the recent questioning about whether meaningful use has had its intended effect and even whether current EHR systems are safe also makes me optimistic that people are starting to care about quality.

Keep that in mind as you pitch me for the upcoming HIMSS conference. Also keep in mind that I have two distinct audiences: CIOs read InformationWeek Healthcare, while a broad mix of innovators, consultants and healthcare and IT professionals keep up with my work at MobiHealthNews. For the latter, I’m interested in mobile tools for doctors and on the consumerization of health IT.

I’m not doing a whole lot of feature writing at the moment, so I’d like to see and hear things I can relate in a 500-word story. Contract wins don’t really interest me since there are far too many of them to report on. Mergers and acquisitions as well as venture investments matter to MobiHealthNews but not so much to InformationWeek. And remember, I see through the hype. I want substance. Policy insights are good. Case studies are better, as long as we’re talking about quality and safety. Think care coordination and health information exchange for example, but not necessarily the technical workings behind the scenes.

And, as always, I tend to find a lot more interesting things happening in the educational sessions than in that zoo known as the exhibit hall. I’m there for the conference, not the “show.”

Many of you already have sent your pitches. I expect to get to them no later than this weekend, and I’ll respond in the order I’ve received them. Thank you kindly for your patience.

Health Wonk Review gets hung up on insurance

The last edition of Health Wonk Review prior to the Nov. 6 presidential election falls into the familiar big-media trap of portraying the Patient Protection and Affordable Care Act, a.k.a. Obamacare, as being only about health insurance and of effectively equating health insurance to healthcare. Let me repeat: insurance is not the same thing as care, and having “good” insurance does not guarantee good care.

This installment of HWR is awfully heavy on the insurance aspects of the ACA in the context of politics the election, which is not surprising, though host Maggie Mahar of the HealthBeat blog does at least consider comparative-effectiveness research, thanks to a contribution on the esteemed Health Affairs Blog.

My post, which includes the infographic from the movie “Escape Fire” showing how medical harm essentially is the No. 3 cause of death in the U.S., is almost an afterthought, but at least Mahar also includes an entry from Dr. Roy Poses about medical harm in clinical trials.

There’s nary a word on health IT, which really is a shame in the context of the election, especially given that several Republican members of Congress, including Sen. Tom Coburn, M.D. (R-Okla.), have publicly questioned whether “meaningful use” so far has led to higher utilization of diagnostic testing and thus higher Medicare expenses.

By the way, Healthcare IT News is currently running a poll that asks: “With four GOP senators calling on HHS to suspend MU payments, would health IT remain bipartisan if Romney became president?” The poll is on the home page, but even after voting, I couldn’t find the results. In any case, I personally believe health IT has enough bipartisan support for MU to continue.

I also believe that no matter who wins the presidency, Congress probably will remain divided for the next two years, with Democrats holding onto the Senate and the GOP retaining control of the House, so I don’t expect any controversial legislation to pass. A Romney administration possibly could put a hold on future MU payments or revise the Stage 2 rules, but never underestimate the power of the hospital and physician lobby.

Medical harm explained, in graphics and Farzad style

INDIAN WELLS, Calif.—Still think the United States has the “best healthcare in the world?” You clearly haven’t been paying attention.

Last month, the Wall Street Journal ran this excellent commentary from Johns Hopkins surgeon Dr. Marty Makary about how the broken culture of medicine is harming people. An excerpt:

I encountered the disturbing closed-door culture of American medicine on my very first day as a student at one of Harvard Medical School’s prestigious affiliated teaching hospitals. Wearing a new white medical coat that was still creased from its packaging, I walked the halls marveling at the portraits of doctors past and present. On rounds that day, members of my resident team repeatedly referred to one well-known surgeon as “Dr. Hodad.” I hadn’t heard of a surgeon by that name. Finally, I inquired. “Hodad,” it turned out, was a nickname. A fellow student whispered: “It stands for Hands of Death and Destruction.”

Makary went into a discussion of checklists, à la Gawande, and reporting of adverse events. “Nothing makes hospitals shape up more quickly than this kind of public reporting,” he said. Yep, a little shaming can be good for consumers. And shocking.

Now playing in a fairly small number of theaters and available on DVD, on demand and through iTunes is a new movie called “Escape Fire,” which takes its title from the Don Berwick book of the same name. I have not been to see it yet — soon — but the trailer is compelling. So is this graphic, which the movie’s producers are circulating on social media:

Still think we don’t have a problem with patient safety in this country? Not only haven’t you been paying attention, you also haven’t heard Dr. Farzad Mostashari tell the heart-wrenching story of accompanying his mother to an emergency department shortly after he joined the Office of the National Coordinator for Health Information Technology in 2009.

He couldn’t get answers about his mother’s condition from anywhere in the department, and not because the doctors and nurses didn’t want to do the right thing. “The systems are failing them,” Mostashari said Wednesday at the College of Healthcare Information Management Executives (CHIME) CIO Forum, where I am now.

Even as a physician, he felt like he would be imposing on the doctors and nurses on duty if he requested to look at his mother’s paper medical record to see what might be wrong. “There was something rude about trying to save my mom’s life by asking to see the chart. That’s messed up,” Mostashari said.

Yes, yes it is. And Mostashari later told me he shared that story for me, because I had told him right before he went on stage about the suffering my dad needlessly suffered in a poorly managed hospital in my dad’s last month of life. Journalists don’t often say this, but thank you, Farzad.

As it turns out, the CIO of the health system that owns the hospital that mistreated my dad is here. I introduced myself and gave a brief synopsis of what happened, in a non-confrontational way. I intend to follow up. The hurt of losing my dad is still fresh, but I feel inspired by the media soapbox I have.

I want to honor my dad’s legacy in a positive way. I want to help this hospital fix its terrible processes and toxic culture so others won’t have to suffer the way he did.

Podcast: This time, I’m the interviewee

In a rare turn of events, I’m the one being asked the questions on a podcast by Sivad Business Solutions, which hosts regular audio discussions on a variety of business topics. I give kind of a high-level view of health IT and offer my very strong opinions on patient safety and healthcare reform. There’s an interesting discussion about EHRs being designed to maximize reimbursements rather than assure safety.

Interestingly, we recorded this via Skype. I like the audio quality, if not the nasal quality of my own voice, more than usual that day.

Hopefully the embedded audio works. If not, click here.

ACA decision is a beginning, not an end, to health reform

I’ve spent a lot of time on social media since Thursday morning debating the meaning of the Supreme Court’s rather stunning decision on the Patient Protection and Affordable Care Act. It was stunning in that Chief Justice John Roberts, a George W. Bush appointee, sided with the four liberal-minded justices, but also stunning in that the court went against conventional wisdom by upholding the individual mandate on the grounds that it was a legal exercise of Congress’ constitutional right to levy taxes.

I had to remind a lot of people that this decision neither solves the crisis, as supporters have claimed, or turns us into the Soviet Union, as some on the lunatic fringe have suggested. Expanding insurance only throws more money at the same problem. This was my first tweet after I learned of the decision:

Breaking news: American #healthcare still sucks. It's quality, stupid. #ACA #hcr #SCOTUS #Obamacare

June 28, 2012 7:11 am via UberSocial for BlackBerry ReplyRetweetFavorite

@nversel

Neil Versel

The cynic in me likes to point out that the individual mandate was an idea first conceived by the conservative Heritage Foundation and championed in Massachusetts by Mitt Romney. Both somehow now oppose the idea. The law that ultimately passed Congress was written by Liz Fowler, a top legal counsel to Max Baucus’ Senate Finance Committee who previously was a lobbyist for WellPoint. Her reward for doing the bidding of the insurance industry was for Obama to appoint her deputy director of the Office of Consumer Information and Oversight at HHS. This was insider dealing at its finest, as much a gift to insurers as the 2003 Medicare Prescription Drug, Improvement and Modernization Act was a gift to Big Pharma.

Of course, I initially was misinformed about the Supreme Court ruling because CNN jumped the gun (as did Fox News) and erroneously reported that the court had struck down the individual mandate on the grounds that it violated the Interstate Commerce clause of the Constitution. But so were millions of others.

I suppose that was fitting, since the national media have for more than two years been misinforming the public about what is really in the law. There are small but real elements of actual care reform — not just an insurance expansion — in there, but very few have been reported. The actual reform has been drowned out by ideologues on both sides. Here’s a handy explanation of most of what’s really there (it’s a good list but not exhaustive). The insurance expansion, the only thing people are talking about, really is just throwing more money at the problem. There is a lot more work to be done to fix our broken system.

What I consider real reform in the ACA includes accountable care organizations and the creation of the Center for Medicare and Medicaid Innovation. Along with the innovation center, CMS also gets the power to expand pilot programs that are successful at saving money or producing better outcomes. In the past, successful “demonstrations” would need specific authorization from Congress, which could take years.

Notice that there isn’t a whole lot specific to IT. That’s because the “meaningful use” incentive program for EHRs was authorized by the 2009 American Recovery and Reinvestment Act. Another key element of real reform that also is not part of the ACA is Medicare’s new policy of not reimbursing for certain preventable hospital readmissions within 30 days of discharge.

We need more attention to quality of care. Many have argued that tort reform needs to be part of the equation, too, because defensive medicine leads to duplicative and often unnecessary care. Perhaps, but lawsuits are a small issue compared to the problem of medical errors. Cut down on mistakes and you cut down on malpractice suits. Properly implemented EHRs and health information exchange — and I do mean properly implemented — will help by improving communication between providers so everybody involved with a patient’s care knows exactly what’s going on at all times.

All of these facts lead me to conclude that true healthcare reform hasn’t really happened yet. Look at this Supreme Court ruling as a beginning, not an end, to reform.

Health reform is so much more than insurance

The headline above shouldn’t surprise regular readers or anyone who knows me. I’ve been saying for a couple of years to anyone who asks me about “Obamacare” or any other aspect of healthcare reform—and many people who haven’t asked—that the public debate and media coverage have been about insurance reform, not care reform, and health insurance is not the same thing as healthcare. I’ve publicly chided the national media, too.

Maybe that is changing. Last month, attorney Philip K. Howard, chairman of advocacy group Common Good (an organization working to “fill the substance void in the 2012 election by offering new solutions to fix broken government”), wrote in The Atlantic that no matter what the Supreme Court does with the Patient Protection and Affordable Care Act, healthcare still will remain inefficient and expensive. “The Affordable Care Act, aka Obamacare, strives for universal coverage. While it encourages pilots for more efficient delivery systems, the overall effect is to exacerbate the unaffordability of American health care. In this sense, the upcoming Supreme Court decision on constitutionality is just a side skirmish,” Howard said.

In other words, as I’ve been arguing for two years, the insurance expansion of this supposed comprehensive “healthcare reform” legislation is simply throwing more money at the same problem. Having insurance doesn’t assure you good care, nor will it by itself even reduce overall costs. It just shifts costs. There was more reform in the HITECH section of the 2009 American Recovery and Reinvestment Act, in the form of the $27 billion incentive program for “meaningful use” of electronic health records than there is in the part of the ACA being widely debated in this election year.

That’s why, as I pointed out Friday, I was happy to see that investigative journalism organization ProPublica has started a Facebook community for people to share stories of patient harm. And today, the New York Times discussed actual healthcare quality in one of its Sunday editorials (h/t Jane Sarasohn-Kahn). The Times highlighted efforts at Virginia Mason Medical Center in Seattle, Cincinnati Children’s Hospital Medical Center and hospital alliance Premier, saying, “It is a measure of how dysfunctional the system has become that these successful experiments — based on medical sense, sound research and efficiencies — seem so revolutionary.” Indeed.

By the way, my recent, controversial post arguing that faxing should be considered malpractice isn’t a new thought I’ve had. I just rediscovered my January 2011 commentary in Columbia Journalism Review about media coverage of telephone-based “telemedicine.” I ended the piece by advising fellow journalists to “start asking the health-care organizations you cover why they still rely on old-fashioned telephones and fax machines.” Malpractice or not, legal or not, it’s more than a decade into the 21st century, yet we still view healthcare through a 20th-century lens.

Or, as I also like to say, it’s quality, stupid.

Facebook community for reporting patient harm

Kudos to investigative journalism organization ProPublica (yes, some journalists still have integrity today) — and a hat tip to HealthLeaders for bringing it to my attention — for setting up a Facebook community for people to report stories of patient harm. I’ve just shared the story of my dad’s torturous final month. I’m glad that a news organization with wide reach beyond the healthcare and technology industries cares about real stories, not distractions related to insurance coverage and partisan politics.

The group now has 661 members. There really should be 1,000 times as many. Please join and share your own stories, then help get the word out about the poor state of U.S. hospital care. (Note that I only accept Facebook friend requests from people I know personally.)

NPR examines hospital quality problem

I knew my dad was not alone in experiencing poor hospital care. Thousands of people are harmed in hospitals every week. Yet, some politicians and pundits still insist America has the “best healthcare in the world.”

Just this morning, NPR helped dispel this myth with a report on the myriad problems with U.S. healthcare—including the quality problem. Read and listen here. And share with your friends both inside and outside the healthcare industry. Share my dad’s story. Share your own stories. Let’s make this priority No. 1. Too many people die and suffer unnecessarily in this country.

Faxing should be malpractice

As you undoubtedly know by now, I am now officially all about patient safety. (Thanks, by the way, for all the support in the wake of my father’s untimely death.) That’s why I was so upset to read a friend’s recent Facebook status update: “So I discovered the real reason why I was in the hospital last week (and not generally feeling well for the past 4.5 months). My doctor’s office faxed a prescription to my mail order pharmacy that was 2x the dose I was expecting.”

In case anyone has forgotten, fax is technology from the late 1980s and early ’90s. It is now 2012. I cannot remember the last time someone asked me if I had a fax number. Yet, inexplicably, this obsolete means of transmitting low-res images—images, not computable data—remains perfectly acceptable in healthcare.

Here’s a radical proposal: medical societies and state medical pharmacy boards should prohibit the use of faxes. Medical errors related to faxed documents should be considered malpractice. Period.

Mark Versel, 1944-2012

My father passed away late last Friday night from a most insidious disease called multiple system atrophy (MSA). It’s a rare, progressive, neurodegenerative condition that presents itself with symptoms similar to those of Parkinson’s disease, but it is far more aggressive and debilitating. Essentially, muscles stop working until the disease kills you. In my dad’s case, he ultimately lost the ability to breathe.

Nobody knows the cause of MSA and there is no cure. There really aren’t even any effective treatments. You can only treat the symptoms with medications designed for Parkinson’s to address muscle stiffness, balance and such, and with physical and speech therapy, but that’s like standing in front a speeding train with a stop sign. It’s a futile battle.

My dad never had any real health issues other than sciatica until he was diagnosed with what was thought to be Parkinson’s less than five years ago (MSA didn’t really come into the picture until maybe a year and a half ago). He ate well, exercised somewhat regularly and generally took pretty good care of himself before the disease came along. Now he’s dead at the relatively young age of 68 after an excruciatingly fast decline that kept him hospitalized for his final month.

He fought the disease valiantly and courageously, but he never got the chance to retire. He was forced to stop working because he was physically unable to continue. He never even got to come home to die. The end came so fast that we didn’t get past the first hospice discussion.

As sad as it is to lose my dad in the way that I did, I want something positive to come out of his ordeal. He was selfless, kind and generous in life, and my family intends to carry on his legacy in some way that we haven’t had time to figure out just yet. I want to use his memory and my little corner of the Internet to help educate people about MSA and about patient safety.

What does patient safety have to do with this, you ask? My dad had pretty terrible care at a poorly run community hospital near his home for more than three weeks before he was transferred to the wonderful Georgetown University Hospital in Washington for what turned out to be his final days. The contrast was striking.

The community hospital was a place of inadequate communication, broken processes, obsolete workflows, neglect and harm. My dad came in with what turned out to be a urinary-tract infection. They treated that with antibiotics, but he developed pneumonia in a matter of days—a condition a doctor admitted he had acquired in the hospital. So he was transferred to intensive care, where the hospital could make a lot more money despite being responsible for the complication. (Perverse incentives rule in American healthcare.) My dad was a Medicare beneficiary, so you and I, as taxpayers, get ripped off by the incompetence.

Meanwhile, the clinicians there, who had been trained to treat the acute symptoms, neglected the MSA for more than a week, even taking him off his regular meds for several days, during which time my dad’s muscles continued to stiffen. Physical therapy was essential to prevent further atrophy. The order went in for him to receive physical and occupational therapy at least three times a week, but the PT and OT were nowhere to be found for a week or more.

Meds that had been ordered didn’t get delivered. One night while I was there, a perky medical assistant or tech or someone of that ilk burst into the room announcing it was time for an AccuCheck test, and nearly went through with taking a small blood sample before I stepped in to ask what was going on. She explained that it was a test for blood sugar (who would know what AccuCheck was if they didn’t have diabetes or some familiarity with the healthcare industry?) only after I enquired, but I stopped her to tell her that my dad did not have diabetes. Because of the MSA, he had difficulty speaking and would not have been able to stop someone acting so quickly. It turned out that the tech had gone to the wrong room. The hospital did require clinicians to scan bar codes before administering tests and meds, but who knows if the system really worked?

Later that evening, the nurse nearly gave my dad an eye drop that had not been ordered. The proper instructions were to administer an ophthalmic drug orally, but only if he had excess saliva. The nurse didn’t see that part of the note, despite the fact that the ICU had a partial EHR (Cerner, for those of you keeping score at home) with electronic medication lists.

The infectious disease specialist at the community hospital was not even familiar with MSA — and he didn’t bother to tell us that for three weeks. It should be his professional duty to call in an experienced neurologist or consult with my dad’s personal physician.

Worst of all, my dad stopped breathing for a few seconds last week under questionable circumstances and was intubated, despite the fact that he had an advance directive on file specifically stating that he did not want to be intubated.

At Georgetown, we saw nothing but compassion and competence. Care was well coordinated. People talked to each other. Clinicians huddled together during shift changes to discuss all the patients on the ward. The medical director of the ICU, a pulmonologist, personally managed my dad’s case. The neurologists at this major teaching hospital had seen MSA before, but that didn’t stop them from talking with my dad’s personal physician. It was too late to save my dad’s life, but he died comfortably and with dignity at Georgetown, without the needless agony he endured at the other place.

I am now vowing to dedicate my own career to educating as many people about MSA as possible and about the danger of uncoordinated care and poorly designed workflows. Interestingly, one of the last stories I wrote before my father passed and before I took leave was a piece in InformationWeek about patient engagement. I love the mantra of the Society for Participatory Medicine that I mentioned in the story: “Nothing about me without me.”

Every patient should live by those words. And every healthcare facility should respect that concept.

Rest in peace, Dad. You have not died in vain.

UPDATE, April 2013: If you would like to make a donation to MSA support and research, please visit our family’s fundraising page, which is helping the Multiple System Atrophy Coalition. Thank you.

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My HIMSS will be all about quality and patient safety

Health Wonk Review gets hung up on insurance

Medical harm explained, in graphics and Farzad style

Podcast: This time, I’m the interviewee

ACA decision is a beginning, not an end, to health reform

Health reform is so much more than insurance

NPR examines hospital quality problem

Faxing should be malpractice

Mark Versel, 1944-2012

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