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When you talk health reform, don’t forget quality and IT, in that order

In my previous post, I was perhaps a bit too critical of Maggie Mahar in her hosting of last week’s Health Wonk Review. I noted that there was not a word about health IT in that rundown, but that’s not her fault. A host can only include what’s submitted, and apparently nobody, myself included, who contributed to HWR bothered to submit a blog post about health IT this time around.

But I continue to be troubled by this fixation so many journalists, pundits, commentators, politicians and average citizens have on health insurance coverage, not actual care. I blame most of the former for the confusion among the populace. People within healthcare know that you can’t talk about reform without including the serious problems of quality and patient safety, and people within reform know that IT must be part of the discussion even if they don’t always say so.

I would like to draw your attention to a story of mine that appeared on InformationWeek Healthcare this morning, about a report on care integration from the esteemed Lucian Leape Institute. The report itself did not say a lot about IT, but the luminaries on the committee that produced the paper are aware of the importance.

I was lucky enough to interview retired Kaiser Permanente CEO David M. Lawrence, M.D., who told me there has been “little attention” paid to the importance of a solid IT infrastructure in improving care coordination and integration. “What you now have is too much data for the typical doctor to sift through,” Lawrence told me.

That’s exactly the message Lawrence L. Weed, M.D., has been trying to spread for half a century, as I’ve mentioned before. And that’s pretty much how longtime patient safety advocate Donald M. Berwick, M.D. — also a member of the Lucian Leape Institute committee that wrote the report — feels. Berwick hasn’t always advocated in favor of health IT in his writings and speeches, but he has told me in interviews that the recommended interventions in his 100,000 Lives Campaign and 5 Million Lives Campaign are more or less unsustainable in a paper world.

Isn’t about time more people understand that widespread health reform is impossible without attention to quality and that widespread quality and process improvements are impossible without properly implemented IT?

 

 

October 29, 2012 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Berwick, after the fact

The tragedy of Dr. Don Berwick’s short tenure as head of the Centers for Medicare and Medicaid Services has been well-documented, including right here on this blog. Berwick got in by a controversial recess appointment because President Obama didn’t have the political courage to fight for his nominee and allow Berwick to face the Democratic-controlled Senate. Berwick, of course, quit late last year when it became clear Obama would not renominate Berwick for the job he is uniquely qualified for.

There have been a number of postmortems in the press, where Berwick discussed his experience running CMS, including the challenges of implementing both the HITECH Act and the Patient Protection and Affordable Care Act and his. continuing efforts to improve the quality of care in this country. But I haven’t seen one quite as good as what Dan Rather just produced.

The former CBS News anchor has been toiling in relative obscurity at HDNet, a hard-to-find cable network run by billionaire Mark Cuban. Fortunately, Rather took to the far more popular Huffington Post this week to share his thoughts on a recent interview he conducted with Berwick.

“Dr. Don Berwick, a pediatrician by training, came to Washington with a sterling reputation among people who actually know something about health care. He had helped pioneer the Institute for Healthcare Improvement, which may sound like another pointy-headed D.C. think tank, but really is a Cambridge, Massachusetts-based organization lauded the world over for helping make health care systems better. For example, they have worked with hospitals on common sense techniques to reduce hospital infections. These are serious people who are welcomed in hospitals and clinics across the country and around the world,” Rather wrote on HuffPo.

That’s right, Rather understood Berwick’s background, unlike, say Dr. Scott Barbour of a crackpot group called  Docs4PatientCare. “Utilizing quotes from Dr. Berwick, Dr. Barbour exposed that, ‘He is not interested in better health care. He is only concerned about implementing his socialist agenda,’” read a pitch I received from that organization last year.

I’ve been over this before. Berwick has probably done more to improve the quality of care and save lives than anybody else on the planet today. Some of the people who publicly opposed his nomination privately knew this, as Rather’s interview with Berwick demonstrates:


Yes, most of the opposition was an elaborate lie perpetrated for political gain. In today’s Washington, is anybody surprised? The losers once again are the American people and anybody who comes to this country for healthcare.

February 16, 2012 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

10 years later, there’s still a quality chasm, and Senate Dems are wusses

It’s been a full decade since the Institute of Medicine published the second volume in its landmark series on patient safety and quality of care, Crossing the Quality Chasm. We appear to be not much closer to achieving a high-quality health system as we were 10 years ago.

Last week, as you may have already heard, a paper in Health Affairs from researchers at the University of Utah concluded that adverse events may be 10 times more prevalent than previously believed and that errors may occur in an astounding one-third of all hospital admissions. The research team, which included such luminaries as Dr. David Classen, Dr. Brent James and the Institute for Healthcare Improvement‘s Frank Federico, also said that their estimates probably were on the conservative side.

Patient-safety advocate Regina Holliday finagled her way into the Health Affairs briefing on the subject on Thursday, and was disappointed by her observation that patients were almost an “afterthought” in a discussion on how to close the gaping chasm. Holliday, a sometimes painter, expresses her frustration in words in this interesting blog post and on canvas. Note that she depicts Accountable Care Organizations as a unicorn.

Do I have to remind you of who used to be the driving force behind the IHI? That of course would be Dr. Donald M. Berwick, the administrator of CMS that Republicans want to kick to the curb because they think they can score political points against the Obama administration. For that matter, the Obama administration and Democrats in the Senate are willing to sacrifice Berwick because they clearly lack the cojones to stand up for better healthcare. Yes, I said cojones. Sue me.

Please read and share my series of posts on Berwick if you haven’t done so already.

Berwick political saga is a tragic attack on better healthcare (March 14)

More reasons why CMS needs Berwick (March 20)

Slams on Berwick getting pathetic (March 23)

 

April 10, 2011 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Berwick political saga is a tragic attack on better healthcare

President Barack Obama has made plenty of mistakes in his first two-plus years in office, but none may be more serious for the future of America than his decision to install Donald M. Berwick, M.D., as a recess appointment to head the Centers for Medicare and Medicaid Services in July 2010.

Berwick really is a great choice to head CMS, but the underhanded nature of the recess appointment has provided fodder for all kinds of uninformed ideologues and assorted nut jobs to attack Obama’s healthcare reform efforts. Just as CMS is gearing up to release widely anticipated proposed regulations for Accountable Care Organizations, we get the sad news that that Berwick’s days are numbered.

After refusing to allow Berwick to testify before the Senate last year, Obama renominated Berwick on Jan. 26. Newly empowered Republicans went on the attack. “The White House’s handling of this nomination—failing to respond to repeated requests for information and circumventing the Senate through a recess appointment—has made Dr. Berwick’s confirmation next to impossible,” the widely respected Sen. Orrin Hatch (R-Utah) said, according to American Medical News.

On March 4, Politico reported that Senate Democrats had given up on the nomination, despite the fact that Berwick had the support of the Medical Group Management Association, the American Hospital Association, the American Public Health Association and, notably, the Republican-leaning American Medical Association and America’s Health Insurance Plans.

How did this happen?

As I wrote last November when Republicans proposed de-funding of the Center for Medicare and Medicaid Innovation, a key element of real reform in the widely misunderstood “healthcare reform” legislation (the main misunderstanding is that insurance is not the same thing as care):

The Patient Protection and Affordable Care Act, widely referred to as “healthcare reform” and mocked by some as a government takeover of healthcare, aka “ObamaCare,” is not popular in Republican circles. That’s no secret.

It’s also well known that, in their drive to repudiate everything Obama, many Republicans, giddy over their victory in last week’s midterm election, have said they want to repeal the PPACA in its entirety, throwing out the baby with the bathwater. (You know, our healthcare system is wonderful the way it is, so we didn’t need any changes in the first place.)

What really got me was the news that some of the more conservative and libertarian elements of the GOP are specifically threatening to pull the $10 billion in funding already authorized for the Center for Medicare and Medicaid Innovation, a CMS program created by the PPACA. This is a center that CMS Administrator Dr. Donald Berwick has called “the jewel in the crown” of the reform bill, and Berwick has unfairly been labeled a socialist, granny-killing pariah by some right-wing zealots who have no idea of his life-saving work at the Institute for Healthcare Improvement.

The new Republican-majority House of Representatives could not make a bigger mistake than defunding the Center for Health Innovation. For years, conservatives have complained of Medicare’s plodding bureaucracy impeding innovation—you know, the very thing the program is intended to foster.

What the PPACA does is allow CMS, via this new innovation center, to try new ideas without having to make sure their experiments are budget-neutral from the start. (The requirement for budget neutrality is why Medicare pay-for-performance and pay-for-prevention initiatives have never really gotten off the ground.) And CMS no longer has to be content with small demonstrations. Instead, the Center for Medicare Innovation is authorized to run wider-scale pilots and then seek congressional appropriations to ramp up any program that proves successful in producing better care for less money.

That’s how you bend the cost curve, a favorite term in policy circles. Killing the Center for Medicare and Medicaid Innovation would just perpetuate the ugly status quo.

That commentary drew five responses on the site, four of which were negative. And every last one of the negative comments were written anonymously. The only commenter to list a name also happened to be the lone supportive response.

I am in no way surprised. Politically motivated lies abound about Berwick, and few of the critics want to be held accountable for misleading the public.

The week before last, I was somewhat critical of the Lucidicus Project and Jared M. Rhoads, who hosted the most recent Health Wonk Review. He did a fine job hosting HWR, but in scanning some earlier posts on the Lucidicus site—hewing closely to confused, angry, misguided ideology of the tea party—I noticed something that got my blood boiling.

On Jan. 27, Rhoads wrote that Berwick was “on a one-way path,” a path that leads to socialism and a government takeover of healthcare. “Without free-market solutions on the table, the one-way march to an NHS-like system will continue. Berwick has just one solution in mind for the problems created by government: more government.”

He also wrote, “Berwick is openly enamored of the U.K.’s National Health Service (NHS) model, in which the government essentially makes decisions for people about the care that they receive, and in which patients can be penalized for attempting to pay for additional care out of their own pockets. The system is characterized by bureaucracy, rationing, and redistribution of wealth and resources.”

At least give Rhoads credit for not cowardly hiding behind a cloak of anonymity.

Yes, it is true that Berwick has publicly spoken of his admiration for the NHS, but it was more about the British decision to make quality improvement a key element of healthcare than it was about a desire to bring an entirely government-run system to the United States. In my post about that edition of HWR, I asked if Berwick hadn’t done more to prevent needless deaths and adverse events than pretty much anyone else alive today.

That’s the same question I asked in an e-mail to the anti-reform (read “crackpot”) group called Docs4PatientCare. Why do I say crackpot? The Atlanta-based organization contacted me last fall with links to a series of videos, including one from group representative Scott Barbour, M.D. According to the original pitch to me, “Utilizing quotes from Dr. Berwick, Dr. Barbour exposed that, ‘He is not interested in better health care. He is only concerned about implementing his socialist agenda.’”

In another video, Docs4PatientCare Vice President Fred Shessel, M.D., said of Berwick, “This is a man who has made a career out of socializing medicine and rationing care for the very young, the very old and the very sick. It is a backdoor power grab. It is dragging our country down the road to socialism and we should resist it.”

I responded to this pitch with a short question: “Berwick isn’t interested in better care? Do you know anything about his work at IHI?” I never got a response. Docs4PatientCare seemingly was trying to hoodwink media that don’t know any better and/or care more about politics than facts.

Here are the facts, from another piece I wrote last year:

A longtime champion of patient safety, Berwick co-founded the Institute of Healthcare Improvement in 1989 and led it until he became CMS administrator by virtue of a controversial “recess appointment” in July 2010, preventing the Senate from questioning him about his views. At IHI, Berwick created and championed the 100,000 Lives Campaign, an effort to prevent that many deaths in an 18-month period by getting thousands of U.S. hospitals to follow simple, preventive safety measures voluntarily. The program later turned its focus to nonlethal adverse events and became the 5 Million Lives Campaign. Berwick is a pediatrician who also holds a master’s degree in public policy.

In kicking off the 100,000 Lives Campaign in December 2004, Berwick made the following audacious challenge to American hospitals: “I think we should save 100,000 lives. I think we should do that by June 14, 2006. 9 a.m.” At that appointed hour 18 months later, he announced that the campaign had prevented 122,300 unnecessary deaths. Berwick was careful not to make IT a prerequisite for participating in either campaign, but he’s come to see the benefits of EMRs and clinical decision support. Now, as head of CMS, he effectively leads the “meaningful use” incentive program. Though the Stage 1 rules were mostly done by the time he took the reins, you can be sure Berwick will be pushing for true quality improvement in subsequent stages of meaningful use.

The key word in the above passage is “voluntary.” There were no mandates when the private-sector IHI encouraged hospitals to do what is right for patients.

Months later, Berwick has indeed been pushing for true quality improvement in meaningful use. I’ll have more on that later in the week.

March 14, 2011 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

A modest proposal

Medical informatics needs a rock star. Not a David Brailer-esque figure who could excite people in the technology sphere, but perhaps a Don Berwick type who can reach every level and constituency of healthcare, and even capture the imagination of the general public.

I had this thought yesterday during a highly engaging session at the American Medical Informatics Association‘s annual symposium in Washington, a session with the mouthful of a title, “Harnessing Mass Collaboration to Synthesize and Disseminate Successful CDS Implementation Practices.” In English, that means panelists were discussing the forthcoming “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide” and related feedback mechanisms, including a wiki.

During the session, panelists discussed the difficulties they’ve had in getting clinical decision support integrated into EMR and quality-improvement projects, as well as into medical practice itself. One commenter from the audience, a Veterans Affairs doctor, noted that to too many people in healthcare, CDS sounds like an IT issue, not something related to quality.

To this, Dr. Bill Bria, chairman of the Association of Medical Directors of Information Systems, said, “Our profession has really stumbled on this one.”

Then, AMIA CEO Dr. Don Detmer asked if the informatics community could identify perhaps the top five serious preventable outcomes and create “poster children” for quality improvement via CDS. He said much of the problem with low adoption of clinical IT is related to communications, though there are some scientific and technology issues as well.

I immediately thought of Berwick and his 5 Million Lives Campaign, a nationwide initiative to help prevent 5 million harmful incidents in healthcare from December 2006 to December 2008 by encouraging hospitals to commit to a series of proven interventions. This, of course, grew out of the 100,000 Lives Campaign, which Berwick’s Institute for Healthcare Improvement says successfully prevented more than 100,000 deaths in U.S. hospitals over a year and a half.

I was at Washington Hospital Center in D.C. just a week ago because my dad had surgery there. Everywhere I looked were signs reminding staff to take action to prevent errors and complications, particularly methicillin-resistant staphylococcus aureus infections. At just about every turn in the hospital corridors, wards, waiting rooms and cafeteria were hand sanitizers.

I’m fairly certain this high level of awareness is directly related to the IHI campaign. In fact, my dad picked Washington Hospital Center over another hospital much closer to his suburban Maryland home because the other place had been in the news of late for its high rate of MRSA. Yes, the public is very aware of the danger of hospital-acquired infections, and Berwick has had a lot to do with raising the issue.

Healthcare needs someone similar to take the lead in communicating the benefits of clinical decision support to the masses. Does informatics have a rock star out there? It’s time to come forward.

November 13, 2008 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.