Quality | Meaningful HIT News

Most ‘sentinel events’ caused by poor communication

LOS ANGELES—I’m on the west coast now, first for the USC Body Computing Conference here Friday, and then for the annual Health 2.0 conference up in San Francisco Monday and Tuesday.

Friday there was a lot of talk of healthcare reform. One interesting — and plausible — idea I heard for the first time is that the new Medicare policy of denying reimbursements for preventable readmissions within 30 days of discharge for patients with heart attack, heart failure or pneumonia might have an unintended consequence: We’ll start seeing a lot of readmissions on or after Day 31.

The new policy is one of the many aspects of true reform in the Patient Protection and Affordable Care Act beyond the controversial insurance expansion. And there seems to be a loophole that you can be sure a lot of hospitals will seek to exploit. Even if they don’t, it is hard to change patient behavior, so it’s likely many will come back to the hospital for the same condition, even if it’s not within 30 days.

More importantly, I heard some statistics presented by Stanford dermatology resident Michelle Longmire, M.D., about medical errors: 7o percent of all sentinel events in U.S. healthcare facilities — and there were 8,859 such events voluntarily reported to the Joint Commission between 1995 and the first quarter of 2012, meaning that many times more probably occurred —result from breakdowns in communication. Half occur during patient handoffs such as shift changes, specialist consultations and transfers to other wards or facilities, Longmire said.

I am convinced all the buffoonery that took place while my dad was hospitalized prior to his death was due to communication problems, poorly designed work processes and a culture of covering one’s posterior in an error-prone organization.

This happens far too often, yet some politicians who want to repeal “Obamacare” keep trying to convince the ignorant masses that American healthcare is just in need of a few tweaks.

At the Republican National Convention in August, New Jersey Gov. Chris Christie said the following: “”Mitt Romney will tell us the hard truths we need to hear to end the debacle of putting the world’s greatest healthcare system in the hands of federal bureaucrats and putting those bureaucrats between an American citizen and her doctor.” PolitiFact.com generously rated this as “half true.” However, PolitFact itself noted that the World Health Organization rated U.S. healthcare as 37th of 191 countries in terms of “overall performance.” The Organization for Economic Cooperation and Development says we spend more on healthcare as a share of gross domestic product than any of the other 33 OECD countries. If that’s the “world’s greatest,” I’d sure hate to be worst.

Last week, during the first presidential debate, former Massachusetts Gov. Mitt Romney, the very same Gov. Romney who championed near-universal health insurance coverage with an individual mandate in his home state — a plan first hatched by the conservative Heritage Foundation as an alternative to the Clinton healthcare reform proposal in 1993 — said this:

Look, the right course for — for America’s government — we were talking about the role of government — is not to become the economic player picking winners and losers, telling people what kind of health treatment they can receive, taking over the healthcare system that — that has existed in this country for — for a long, long time and has produced the best health records in the world.

Without getting into what the role of government should or should not do, our health records suck, Our record on producing healthier people is not so wonderful, either. So no matter what Romney meant by “best health records in the world,” he was lying.

I couldn’t help thinking he was playing to this crowd:

Now, this cartoon makes it seem like Obamacare is so wonderful. It’s not. As I’ve said before, having insurance does not mean you will get good care. Having “good” insurance that requires very little out-of-pocket for the patient doesn’t guarantee good care, either, nor does being a VIP. Recall the case of James Tyree, who died from a medical error at a prestigious teaching hospital he was on the board of. The late Rep. John Murtha (D-Pa.) suffered a similar fate despite having “Cadillac” insurance coverage.

I’m going to repeat what is fast becoming my mantra: It’s quality, stupid.

UPDATE, Oct.8: Here’s a summary of what actually is in the Affordable Care Act, and when each provision takes effect, courtesy of the Kaiser Family Foundation.

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.

Podcast: Carrie Handley on patient empowerment with an iPad

Did you happen to catch my story in MobiHealthNews on Thursday about Carrie Handley, the IT consultant-turned-cancer patient? She got frustrated with first a misdiagnosis and then the hassle of lugging around a binder full of paper records that she had to go to multiple sites to collect to assure continuity of care during her treatment and surgeries. So Handley digitized all her records.

Initially, she transported the information on a USB drive, but that got lost in a doctor’s lab coat. Then, her son brought over an iPad. The tablet provided the right balance of portability and shareability. In this interview, Handley, a resident of Waterloo, Ontario (you know, the home of BlackBerry maker Research in Motion), describes the process and shares her thoughts in general on mobility in healthcare.

We wouldn’t have connected if she hadn’t read my tribute to my dad last month. After reading Handley’s story in the e-mail she sent me, I knew we had to do this podcast to help spread the idea that communication can help foster the kind of patient-centric care that eluded my dad, that initially eluded her and that probably eludes millions of people every year.

This Sunday is Father’s Day. I miss my dad terribly. But I take comfort in knowing that I’m doing a small part to raise awareness of multiple system atrophy (MSA) — the rare neurodegenerative disease that killed him — and perhaps advancing the cause of patient safety ever so slightly.

Podcast details: Interview with health IT consultant and cancer survivor Carrie Handley about mobility in healthcare. MP3, mono, 128 kbps, 26.7 MB. Running time 29:13.

Yes, you do have a right to your health records

Lest anyone forget — including the American Hospital Association, which wants to take 30 days post-discharge to supply copies of medical records to patients — HIPAA explicitly gives patients the right to access their own records. This is not new. The HIPAA privacy rules have been in force since 2002. Yet, far too many patients have no idea of this right and far too many providers don’t inform patients of this right or do what they can to prevent access.

Fortunately, the HHS Office for Civil Rights, which enforces HIPAA privacy and security standards, is trying to change that with an outreach campaign, including this video.

Unfortunately, the video has been viewed just 556 times as of this writing. Equally unfortunately, the video directs viewers to visit HHS.gov/OCR. But the real information you need is at http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. I found that page using Google, not by trying to navigate the menu, which is not very intuitive, even for someone who knows the healthcare industry. I can’t imagine the average consumer finding that page without help or plain old dumb luck.

Various HHS agencies are trying hard to disseminate messages to the public. I think of AHRQ’s Questions are the Answer campaign. I’ve seen poster-size ads around Chicago telling people to visit ahrq.gov for a list of questions they should be asking their healthcare providers, but the better link, not mentioned in the ads, is ahrq.gov/questions.

For that matter — and I mentioned this to one of the AHRQ higher-ups at the HIMSS conference a few months ago — how many people really know what the Agency for Healthcare Research and Quality is? Wouldn’t it be better to have a more memorable URL? The Obama administration is good at setting up URLs for programs it wants to promote for political reasons — think recovery.gov and even the consumer-friendly healthcare.gov — but the less-politicized divisions such as AHRQ (remember, Director Dr. Carolyn Clancy is a career professional who has run AHRQ for two presidents since 2003) and OCR haven’t done so. They need to come up with easy-to-remember URLs that the general public can remember. Bureaucrat-speak just isn’t getting the job done.

Meantime, physicians need to become more patient-friendly, too. I invite you to check out this Salon article from a few weeks ago entitled, “Listen up, doctors: Here’s how to talk to your patients.” Please share with family, friends and, yes, your doctors. Share the OCR video, too. If OCR can’t make the information easy to find, I will.

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.

A dubious honor from Health Wonk Review

For the very first time, I captured the top spot on the biweekly Health Wonk Review blog carnival, this time hosted by Dr. Jaan Sidorov of the Disease Management Care Blog. Unfortunately, I had to endure my dad’s untimely death after a miserable hospital experience in order to write the piece in question. But if it brings more traffic to that post and, more importantly, more awareness of multiple system atrophy (MSA) and the problem of poorly coordinated care and broken processes in hospitals, I’ll take it.

Since you’re here primarily for health IT, I’ll point you to a couple of relevant items that Sidorov summarizes. In a post actually written back in February, Martin Gaynor, chairman of the Health Care Cost Institute, discusses the organization on the Wing of Zock (the name is explained here) blog. The institute is aggregating claims information from the likes of Aetna, Humana, Kaiser Permanente, UnitedHealthcare and CMS to provide researchers with rich data sets related to healthcare costs and utilization.

“At its most basic, HCCI was formed because a better understanding of health spending can improve the quality of care and save money. If we generate information that makes a difference, then we will be a success,” Gaynor says.

Also, consultant Joanna Relth makes it known on the Healthcare Talent Transformation blog that she is no fan of ICD-10. “I’m sure that the intent of making this massive change to the codes is to improve the accuracy of diagnosis coding so providers will bill more accurately and insurance companies will pay providers and insureds in a more timely fashion. Seriously?? Did anyone ask a learning professional about how large a list is reasonable and at what point does the number of data points become impossible to follow?” she wonders in what comes off a little as an anti-government screed.

But I prefer to end this post on a happy note. In the comment section, Relth links to a video from EHR vendor Nuesoft Technologies that parodies Jay-Z’s “99 Problems.” Enjoy.

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.

Most ‘sentinel events’ caused by poor communication

Podcast: This time, I’m the interviewee

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

Podcast: Carrie Handley on patient empowerment with an iPad

Yes, you do have a right to your health records

Health reform is so much more than insurance

A dubious honor from Health Wonk Review

NPR examines hospital quality problem

Faxing should be malpractice

Mark Versel, 1944-2012

Recent Posts

Calendar

Meaningful Health IT News Resources

Recent Comments

Categories

May 2013
M	T	W	T	F	S	S
« Apr
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30	31