Tuesday, January 26, 2010

Patient Unfriendly Environments

Bridget Duffy is the "Chief Experience Officer" for the Cleveland Clinic and gave a presentation at the first "Gel" conference looking at the patient experience from a personal standpoint when she broke a leg and as she described "became invisible". You can see the presentation here (it is 25 minutes long but worth the time from a provider perspective as well as the patient perspective)

Bridget Duffy at Gel Health 2009 from Gel Conference on Vimeo.

And if that does not work click this link here. Fascinating insight that I can only echo from recent experiences that start long before any interaction with the hospital. Dealing with insurance coverage is an excruciatingly painful experience. When I called my local, friendly and most importantly the pediatric orthopedist who I knew and knew my family I discovered he no longer accepted . There a whole side bar here on why he would stop accepting an insurance but who wants to bet that it has something to do with the pain and agony his office has in getting reimbursed for care and the rates he is forced to accept with those patients.

So now the patient choice is to pay "out of network" or find another provider who you don't know and does not know you (and unless you are religious about collecting your medical records and imaging studies won't have the slightest idea of your medical history). Electing to save money means navigating through the the voice navigation system designed in hell for your insurance company to reach a human being to ask who in the nearby area takes their insurance. Does this feel like rolling the dice in Vegas to anyone else? I spend more time researching the hard drive upgrade for my PC than I have and can spend on where to go for my care. Imagine if you were buying a hard drive but although you liked the Geek Squad at Best Buy could not go there because they did not take your credit card - frustrating. But then again perhaps Best Buy would not want your business if when you bought the hard drive worth $100 but your credit card company actually only paid them $35....

Back to the orthopedic referral - now you have to call the office and spend 15 minutes redialing as the number is constantly engaged! I thought that problem had disappeared along with my Vinyl records! Finally you get through and must finish strong persuading the receptionist that you do need an appointment today. Not unreasonable having placed your 11 year old patient in a painful holding pattern over the weekend because you knew that marching off to the local ER was a gargantuan waste of time and resources and nothing would be done over the weekend anyway. This step alone saved the insurance company hundreds of unnecessary dollars of spending but will never be taken account of.

Does any of this seem broken to you - it does to me and as Dr Duffy explains some of these things are not difficult to fix. If the first things I heard when I attended a medical facility was concern for me and how I appeared to them vs the typical first interaction that is composed of data and financial gathering I'd already feel better treated.
What insurance do you have
What is your Patient ID
Sadly few facilities are likely to find the money or resources to allocate to a CEO (that's a Chief Experience Officer) for their facility or being able to run a Code Lavender that delivers Spiritual Care, Counseling, and arrange of other holistic type support services to departments and staff alike but you can bet that they all need one. There are few I have visited that have the slightest inkling of the challenge patients face every day dealing with their organization. To be clear this is not so much an individual criticism as an institutional one.

Ask yourself this question
Can you facility pass the Mother Test: can you drop your mother at the door of your hospital and leave her there for a few days and know that she has been treated with compassion, care and understanding and will emerge happy and contented at the end of it
If you can answer yes - please tell use where this is so we can direct people to this facility. If the answer is no what can you do to fix this and what would make you feel comfortable with a facility that it would pass your mother test?

Tuesday, January 5, 2010

Ready or Not Electronic Health Records are Coming

The games afoot or as they say in England "Game on".....healthcare standards are published (actually the Notice of Proposed Rule Making NPRM - which can be found here) and supplemented by an article posted by David Blumenthal "Launching HITECH" posted by the New England Journal of Medicine.

As before there are multiple stages that include incentives linked to each of the stages but if we focus on Stage 1 that starts in 2011. This includes electronically capturing health information, clinical decision support for disease and medication management, clinical quality measures all tied with protection and securing of the information (don't forget liability for security breaches is now much further reaching). The investment is made (numbers vary but range from $14 - 27 Billion). To receive incentives providers must use their electronic medical records to improve the overall quality of healthcare delivered by demonstrating achievement of a series of objectives. These include (this is not an exhaustive list but captures the main elements):
  • Entering orders, medications etc in CPOE
  • Maintaining problem lists in ICD9-CM or Snomed-CT coding
  • Maintain active medication list and electronic prescribing
  • Recording vital signs, smoking status
  • Receive and display lab results encoded with LOINC codes
  • Generate patient lists based on specific conditions and generate patient reminders
  • Provide patients with electronic copy and electronic access to their record and discharge instructions
  • Generate a clinical summary for each visit
  • Exchange clinical data with other providers
  • Protect the information, encrypt it and record disclosures
There are others but these are broad categories and groups and represent a major push to genuine electronic medical records that are digital, contain useful data and are shareable between systems. Certification (as currently provided by CCHIT based on their existing criteria and what we know to date about the requirements for meaningful use) has 11 products certified for 2011 - list here. This is a work in progress and expect to see many more and probably other certification bodies.

The overall tenet of this initiative is summarized by Dr Blumenthal in his article:
...so as to reward the meaningful use of qualified, certified EHRs — an innovative and powerful concept. By focusing on the effective use of EHRs with certain capabilities, the HITECH Act makes clear that the adoption of records is not a sufficient purpose: it is the use of EHRs to achieve health and efficiency goals that matters.

There are other strands/programs that are designed to address the obstacles to adoption - summarized in this chart from the NEJM article:

Behind the scenes the health information exchanges that allow for the easy sharing of clinical data between systems, clinical users and patients will be essential.

This is a broad set of criteria and for many clinical practices a long way from where they are now. The shape of this program is clear - sign up and participate now and receive additional funding/payment or wait and be punished later if you do not implement. There remain many challenges not least of all the products and expertise required to roll these technologies out but to me the message is clear - this train is leaving and failing to get on board will will cost you more in the future.

In the first instance we have an opportunity top provide input to the NPRM - the link for this can be found on the main page of the HHS HealthIT page here or the actual system here. Have you managed to wade through the 600+ pages or found a great summary of the content highlighting key aspects - share the knowledge, leave a comment with your thoughts and/or links and help everyone get up to speed with this material and provide input to the rule by the end of February 2010.