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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.

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September 18, 2012 I Written By Neil Versel

Filed Under: Accountable Care Organizations EMR/EHR health reform interoperability meaningful use medical errors mobile Patient Protection and Affordable Care Act patient safety podcast primary care quality reimbursement

Tags:EHR errors EMR interoperability iPad meaningful use Medicaid Patient Protection and Affordable Care Act patient safety patient-centered medical home PHRs Practice Fusion preventive care primary care quality smartphone apps Supreme Court venture capital workflow

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:

[blackbirdpie url=”https://twitter.com/nversel/status/218345950597492738″]

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.

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June 3, 2012 I Written By Neil Versel

Filed Under: ARRA EMR/EHR hospitals meaningful use media medical errors Patient Protection and Affordable Care Act patient safety quality

Tags:ARRA Cincinnati Children's Hospital Medical Center Common Good Facebook fax healthcare costs HITECH Act insurance jurisprudence New York Times Patient Protection and Affordable Care Act patient safety Philip K. Howard Premier Inc. ProPublica Supreme Court The Atlantic Virginia Mason Medical Center

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.)

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June 1, 2012 I Written By Neil Versel

Filed Under: health reform hospitals media medical errors patient safety politics social media

Tags:Facebook Mark Versel patient safety ProPublica quality

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.

$10M settlement in death from medical error

Remember James C. Tyree, the University of Chicago Medical Center board member who died last year from a preventable medical error at the very same hospital he was on the board of? His estate has reached a $10 million settlement with the prestigious teaching hospital for “alleged negligence,” the Chicago Tribune reported.

As I previously wrote, Tyree died from an intravascular air embolism, the result of an improperly removed catheter. That just happens to be one of the National Quality Forum’s so-called “never events.”

Tyree, as chairman and CEO of financial services firm Mesirow Financial, was pretty well-off. He also should have gotten VIP treatment at U. of C. Medical Center since he was a board member. Yet his money and connections could not save him from a preventable error that really should never happen.

Think about that the next time someone tells you that having health insurance automatically gives you access to good care and that the wealthy get better care than the rest of us. Health insurance just means the insurer will help pay the bills — and often the bills rise (as does hospital revenue) — when there’s a preventable error, as seems to be happening with my own father this week. (He’s still in the hospital, though the pneumonia has subsided.) Being a VIP at a teaching hospital just means you might get faster service, more — not necessarily better — care and perhaps direct supervision from executive faculty, not just residents and the occasional attending physician.

Poor quality is epidemic in American healthcare. Don’t let anyone tell you otherwise.

Kudos to David Doherty of Ireland-based telehealth provider 3G Doctor for this summation of the problem, which he tweeted in response to the post about my dad:

[blackbirdpie url=”https://twitter.com/#!/mHealthInsight/status/194376602728140800″]

Keep spreading the word: It’s quality, stupid.

Sen. Whitehouse, make some more noise, please

I have railed more often than I can count against politicians and the national media for misleading or at least failing to inform the public on what health reform is all about. For me, it was quite refreshing to see an interview in the Washington Post with Sen. Sheldon Whitehouse (D-R.I.), attempting to shed some light on the parts of reform that have nothing to do with insurance.

“The Affordable Care Act is mostly known as an insurance expansion, expected to extend coverage to more than 30 million Americans,” started the post by Sarah Kliff. “But … a big chunk of the law is dedicated something arguably more ambitious: an overhaul of the American business model for medicine. ‘This is a very significant piece of the bill that has received virtually no attention because it’s so non-controversial,’ Sen. Sheldon Whitehouse (D-R.I.) told me in a recent interview.”

On Thursday, Whitehouse released a 52-page document outlining what he sees as the 47 changes the Patient Protection and Affordable Care Act is making to how care is delivered. That doesn’t even count the reforms in the HITECH section of the American Recovery and Reinvestment Act from a year earlier, by the way.

Health IT, of course, is a big part of reform.”The HITECH Act took important steps to restructure financial incentives to shift the pattern of health IT adoption. The HITECH Act’s Medicare and Medicaid incentive payments are encouraging doctors and hospitals to adopt and “meaningfully use” certified
electronic health records,” Whitehouse noted.

Also from that report:

Health information technology (IT) will radically transform the health care industry, and is the essential, underlying framework for health care delivery system reform. The ACA’s payment reforms, pilot projects, and other delivery system reforms are built with the expectation of having IT-enabled providers. In particular, the shift to new models of care, like ACOs, will rely heavily on information exchange and reporting quality outcomes. Indeed, the formation of ACOs is contingent on having providers “online” to transfer information and patient records, and report quality measures.

Whitehouse did discuss ACOs with the Washington Post, but there’s a reason why the interview appears on a page called the WonkBlog. This stuff is too complicated and wonky for the average person.

What isn’t complicated is explaining that throwing more money at a broken system, as the insurance expansion does, will not lower the cost of care. It also isn’t complicated to explain that tens of thousands of Americans needlessly die each year due to medical errors or low-quality care. Yet, more than a few defenders of the ACA have said that the insurance mandate would help guarantee “quality care” for millions.

Wrong!

The insurance expansion guarantees insurance coverage. It does not guarantee quality care. Whoever wins Friday’s Mega Millions drawing wouldn’t necessarily be able to buy quality care, either. Nor would Bill Gates, for that matter. You can’t get quality care unless you’re willing to address the causes of errors and adverse events. Period.

Sen. Whitehouse seems to understand that. I doubt too many other members of Congress do, despite the fact that a former colleague, the late Rep. John Murtha (D-Pa.), who had the “Cadillac” coverage so many people covet, died as a result of a medical error.

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March 30, 2012 I Written By Neil Versel

Filed Under: Accountable Care Organizations ARRA health IT health reform Healthcare IT Legislation meaningful use media medical errors Patient Protection and Affordable Care Act patient safety politics reimbursement

Tags:Accountable Care Organizations ARRA insurance John Murtha Patient Protection and Affordable Care Act patient safety quality Sheldon Whitehouse

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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

$10M settlement in death from medical error

Sen. Whitehouse, make some more noise, please

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