Monday, October 20, 2008

Healthcare Myths

Great post from Arthur Garson at titled "Setting the Health Care Record Straight" - where he addresses some of the prevalent myths associated with the problems in the US healthcare industry

The myths as detailed:
1) There's no money - there is it's just wasted (by everyone)

2) New Plan = Government Run Healthcare - no they are not but they are trying to provide more universal coverage.

On the issue of "free" healthcare this is not a simple problem/solution - see the experience in Hawaii whose experiment in offering "free" healthcare to low income families has been suspended as it ran out of money after 7 months.

3) You can't Change it (third rail in politics) - as another poster pointed out there is now sufficient interest/incentive to fix the problems not least of all driven by the economic problems.... American has been and will continue to be an innovator. As a good friend of mine Dr Bruce Merrifield shared with me recently in a paper on global warming and Integrated Patterns of Civilization "about 90% of all recorded scientific knowledge has been generated over just the most recent 30 years, a knowledge base that will likely double again in the next ten years".

I am an optimist like Dr Merrifield and take the view "The current explosion of learning and experimentation now extends to all fields of knowledge with consequences for the future that may be incalculable and certainly under appreciated"

I have no doubt we will find solutions to these issues and many others - our rate of innovation and knowledge sharing is increasing daily and the world is full of latent genius. We just need the incentive and I think recent difficulties and the level of focus are helping provide a spotlight to focus our minds and innovations on solving these issues.

Thursday, October 16, 2008

NQF Issue Brief on Measuring Elements of Care

The recently released issue brief from the National Quality Forum titled "Performance Measurement and Reporting at the Clinician Level" can be found here (pdf file) makes the case for clinicians reporting which like it or not is coming. While many resist and there are difficulties in comparing results in healthcare because of the many contributing variables to outcome it seems impossible for me to imagine the future without comparisons of quality by patients.

For heavens sake - I can compare the quality of a dishwasher, the performance of a store and customer service of a technology provider why should I not want or be able to compare the results of my hospital and clinical service provider.

It is important to remember a point I made before:

Millions of times each day, patients interact with the U.S. healthcare system. During these interactions, most patients receive the benefit of solid clinical judgment and technical expertise from their care providers and witness basic and state-of-the-art technology appropriately applied

And rightly they point out that

Current incentives encourage more care rather than the right amount of care

So the effort underway is to refine these measures to make them better and more helpful and specifically to address the charge of Apples to Oranges that we hear repeatedly when data is published showing poor quality in one institution over another. The current work seeks to address this:

Clinician-level measurement is undergoing refinement. The shortcomings of current measurements are driving concurrent efforts to more broadly define relevant, important, and measurable elements of condition-specific episodes of care and related accountability.

In the Charter they focus on the criteria and attributes that are desirable for measuring clinicians from a patient perspective:

  1. Measures should be meaningful to consumers and reflect a diverse array of physician clinical activities.
  2. Those being measured should be actively involved.
  3. Measures and methodology should be transparent and valid.
  4. Measures should be based on national standards to the greatest extent possible.

But to achieve this as they identify in their discussion paper (Rattray MC, Clinician Level Measurement and Improvement – Improving Reliability, Actionability, and Engagement, Washington, DC: National Quality Forum; 2008) and follow up discussions needs to:

Enrich clinical data. Accelerate efforts to capture relevant clinical data to augment administrative claims data.

To satisfy this need without weighing down the already over burdened clinician requires that this data is enriched as part of the clinical process and not by imposing new and difficult processes onto their current clinical activity. A recent example cited by one of my clinical colleagues had me truly surprised. In this implementation the new clinical system required the clinicians users to be shadowed 1 on 1 for 30 days to help them learn and use the system. If this is what is required there has to be something wrong with the approach and/or the system. Educators are told that if everyone fails their test on material they have delivered to their students then the chances are that there is a problem with the education method, format or delivery and not with 100% of the students. What is surprising to me is that a healthcare facility would consider the necessity to shadow clinicians for 30 days an acceptable aspect of any system..... and rest assured that the cost of this training must be an additional administrative burden on an already stretched healthcare system.

Enriching the clinical data is essential to our move to quality and getting maximum value from our stretched clinical dollars but we cannot capture and impose complex systems and requirements on clinicians to achieve this aim. Use existing processes, tools and resources that are already efficient and use technology to facilitate the enhancement and capture of this information. I am all in favor of new ways and technologies to be applied to healthcare and our lives in general but let's use what is in place and help improve efficiency without burdening the scarcest clinical resource we have - the clinical staff.

Thursday, October 9, 2008

Maternity Care Makes up 25% of Admissions in the US

Obstetric care makes up ~ 1 in 4 discharges from hospital. The Agency for Healthcare Research and Quality reports that admission for childbirth outnumber admissions for pneumonia, cancer and heart failure. Unfortunately for many their view of childbirth is summarized by this quote:
"A lot of people think pregnant women are an accident waiting to happen"
Yikes! Mothers have been having babies for many years - this kind of attitude is reminiscent of the "State of Fear" that is detailed in Michael Crichton's book of the same name. There are some trying to combat this and Rita Rubin's article in USA Today this week: Maternity-care failings can be remedied with cost-saving fixes features some good examples including Valerie King of the Oregon Health & Sciences University who makes an excellent point
"Fortunately, maternity care is a place where good care and good economics come together."
And given the numbers this is a great place to focus. The latest numbers show a big increase in costs with a jump from $79 Billion in 2005 to a $86 Billion in 2006. Of this, estimates are that $2.5 Billion of that cost is associated with unnecessary care (mostly intervention with Cesarean Sections). The latest report published by the Childbirth connection on Evidence-Based Maternity Care focuses on the unnecessary care being delivered and the over use of intervention which is best demonstrated by the Cesarean Section rate in the US which stands at 30% (in the UK the rate is 24% which is also higher that expected)

Key to dealing with this is clinical data so there is no need to repeat unnecessary tests and investigations and making this information readily available will help the clinical staff and making the capture of this information as facile as possible.

You can read more about this at my "Navigating Healthcare Blog" - here which talks about the UK experience and covers some personal guidelines for mothers and parents to consider as they look at care in this area.

Monday, October 6, 2008

EMR Adoption and PHRs

Chilmark Research published a "PHR Market Report, Analysis and Trends" - the Executive Summary is available for free (with sharing of your details). In their blog commentary they make an relevant point
PHRs simply won’t go anywhere without data and arguably the best source of data is a physician EMR system. Unfortunately, the adoption of EMR is abysmal across the care continuum of providers sitting at somewhere around 15-20% depending on how you count it/who you believe.
And even if you believe the 15-20% penetration of this, the vast majority of the information in these systems comes from dictation and transcription and is stored as blobs of text. There is certainly some potential for the personal health records/systems to help drive the capture of more shareable data. There are problems of security and confidentiality but as they suggest I think the benefits will outweigh the risks in the near future, especially given the entry of Microsoft, Google, Intuit and Dossia (there is a piece of my British Heritage that feels this is not the best name choice - see here).

For both PHR's and EHR's to succeed the data has to be shareable.....easily. It has to be as easy as clicking on a link or plugging in a USB stick and selecting import. To see what this needs to look like you need look no further than Facebook which has rapid user adoption. Facebook has exploded onto the social networking scene by offering simple ways for sharing applications, data and tools between all the users.

The HL7 approved CDA format represents the way forward and the potential to bridge the divide between structured and unstructured content. CDA4CDT commenced the process in 2007 and has defined the formats for 4 document types so far and there are more to come. There are several presentations available here. With shareable formats data can be made available from PHRs to EHRs and vice versa. This will drive adoption in both systems.