Free Healthcare IT Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Get all the latest Health IT updates from Neil Versel for FREE!

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.

 

October 7, 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.

$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:

In 2012 where else but the sickcare industry do you make more money by failing http://t.co/pUOebYho Hope Dad gets well soon @
@mHealthInsight
mHealth Insight

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

April 24, 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.

More reasons why CMS needs Berwick

On Jan. 28, Ron Pollack, executive director of the liberal advocacy group Families USA, introduced President Obama at a Families USA event by saying, “Numerous presidents over many decades tried to secure health reform legislation that would move us toward high-quality, affordable healthcare for all Americans. You, Mr. President, actually achieved it.”

The crowd ate it up.

During the contentious debate over health reform in 2009 and 2010, countless lobbyists, pundits and politicians touted “quality healthcare” as a reason to pass the Patient Protection and Affordable Care Act. Some called for the same “Cadillac” health plans that members of Congress provided for themselves. Many opponents of the legislation countered by saying the U.S. already has the “best healthcare in the world.”

The problem was not one of philosophical differences. The problem was a misunderstanding of a basic fact: health insurance is not the same thing as health care.

Still, politicians keep making the same mistake over and over, and the mass media keep giving them a free pass.

Anyone in the healthcare industry knows that the United States does not have the best healthcare in the world. We have the most expensive care in the world. (Another myth often passed off as truth is that more care and more expensive care automatically equals better care.) Having a “Cadillac” health plan won’t assure you better care, either. Just ask the late Rep. John Murtha (D-Pa.), who, as a member of Congress had such a plan, but still likely died as a result of a surgical error last year.

Another such episode occurred last week. James C. Tyree, chairman and CEO of financial services firm Mesirow Financial, died Wednesday at the University of Chicago Medical Center at age 53. Though Tyree had stomach cancer and pneumonia, the official cause of death was an intravascular air embolism, the result of an improperly removed catheter. That’s one of the National Quality Forum’s so-called “never events.”

As the chief executive of a financial firm, Tyree no doubt had the resources and the insurance to get what some people might call “good, quality care.” He also happened to be on the board of the U of C Medical Center, the very same institution that was so proud of being named one of U.S. News and World Report’s best hospitals in America. Yes, even at the “best” hospitals, mistakes happen, and they happen to people with money and connections.

This is yet another reason why CMS needs someone with a long record of quality improvement, even at institutions with supposedly sterling reputations. Someone like Don Berwick.

If you haven’t already, I encourage you to read the defense of Berwick that I wrote last week so you understand why politics is hijacking better healthcare in America.

March 20, 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.