Reviewing the findings of HealthLeaders Media's intelligence report, the Drive to Patient Safetyone gets the sense that top health executives definitely want to steer in the right direction in terms of patient safety. But they also need to get in a faster lane.
Indeed, the survey shows that putting patient safety is among their top priorities, with 91% of the respondents saying it is a key concern. It is an area that health systems seek to be accountable for, says Bertine McKenna, COO of the Bassett Healthcare Network, in Cooperstown, NY, who reviewed the findings.
"That's definitely good news and shows a significant step in the right direction for many healthcare leaders," McKenna says.
Intelligence Report: The Drive to Patient Safety:Free Download.
But there are legitimate concerns over the health leaders' responses about communication and leadership structures tied to formulating patient safety plans. Those don't look good. They are issues that can significantly slow down the patient safety process.
Healthleaders acknowledged in the survey that communication is a potential stumbling block for improved patient safety initiatives as well as an area of risk to patient safety during transition of care.
About 49% of respondents said communication issues were among their strongest concerns. Moreover, an alarming 56% of survey respondents said that important patient information "sometimes" is lost during shift changes. Another 12% said it "often happens," while 27% said it is a "rare occurrence"
When I asked Mary Anne Vincent, vice president of performance improvement at St. Joseph Hospital, in Orange, CA, she said those results are disappointing.
"Communication is a barrier in healthcare. So many times I see issues that could have been avoided or minimized with an extra minute or so of 'one-on-one Communications," Vincent says. In many systems, communication is broken down between nurses and physicians by merely the manner in which they forward their information, she says.
During shift changes, for instance, for some healthcare workers "it's hard to let go of that control," says Shelby Harrington, outcomes specialist for Carolinas Health System, who examined the survey results. But letting go is what needs to be done, she says.
Intelligence Report: The Drive to Patient Safety:Free Download.
An important element in improving communication specifically related to shift changes involves patients themselves, Harrington says. "Giving (patients) a sense of ownership of their own care of what is happening." she said.
"We should be communicating to the patient exactly what we are doing and why we are doing it," Harrington says, "telling that patient, 'I know you've been asked this question, but to ensure your safety, we want to go through your allergy list again.'''
Communication is one thing – between staff and patients. And then there is another level of communication, among hospital staff themselves, and that also appears lacking, the survey shows. Healthleaders are uncertain as to the ultimate responsibility within an organization of who should oversee patient safety initiatives and monitor them.
The survey showed a wide variability of potential leadership for patient safety, ranging from: 25% for executive leadership collectively; 15% for a chief patient safety officer; 14% for a special patient safety committee; 11% for a CEO personally and a designated vice president, and 10% for a chief medical officer.
Lack of consensus is a "sad statement" that reflects potential disorganization in leadership oversight of patient safety, says Vincent. A hospital system can't afford to have a "chief executive who doesn't want to be bothered" with specifics involving patient safety issues," she says.
Intelligence Report: The Drive to Patient Safety:Free Download.
Comments from healthleaders reflect their feelings about the necessity of change and commitment to patient safety as a priority. "We approach it as an area that we do well in, but feel that we can be more effective," says a hospital CEO. Says another: "Patient safety is inextricably linked or tied to the clinical care process, so if patient care isn't the No. 1 financial priority, then the facility is in the wrong business."
The survey shows the manner of communication among staff, physicians and nurses should definitely be improved, McKenna says, "whether it's within a leadership structure on the C-suite level or between physicians and nurses in a hospital room because communication and quality go hand in hand."
In creating and expanding telestroke centers, there is room for variety. Some hospitals and health systems opt for running them on shoestring budgets, or for initiating co-management plans with physician involvement as crucial, integral parts of building relationships among partner hospitals as with patients.
Still, there is concern about developing telestroke programs, especially in rural areas where such networks are badly needed even as some hospital officials struggle to launch them.
These issues came into sharp focus Wednesday at a Health Leaders Media Roundspanel at the Barrow Neurological Institute, St. Joseph's Hospital and Medical Center in Phoenix, AZ. The program was titled, "Neurological Service Line Growth: Telestroke and Brain Tumor Innovations."
Through emerging pathways, hospitals are seeking to improve patient care in telestroke programs with technology as a key factor. But healthcare leaders expressed concern that while IT is good, vital partnerships and collaborations are essential for telestroke or other telehealth programs.
"I'm always looking at lowering the barrier to partnerships," says Alan Pitt, MD, attending physician in radiology and clinical informatics or the Barrow Neurological Institute. "When I look out at the table at a rural access provider, he's usually a relatively small shop and he probably doesn't have the deepest IT resources. And he's listening to you talking about partnership and the first thing he does when he hears telehealth – 'big clunky stuff that he's going to be responsible for. He can't afford big clunky stuff that's going to sit in a closet. We've made this simple. If you have a laptop, you can participate. Telehealth is evolving very rapidly in the ability to partner. Ultimately, it's less about technology and more about the business relationships. If you can eliminate that technology barrier for them."
Indeed, a telestroke network doesn't have to be overwhelmingly expensive and can be carried out on a "shoestring" budget, says Sarah Livesay, MS, RN, ACNP, manager of neuroscience Clinical Programs for St. Luke Hospital in Houston, TX.
She agreed with Pitt that it's not all about technology. "The key to be successful is not necessarily the technology but the relationships you form and the structure you set up with the program," she says. You really need to take a step back in planning the program – develop a process and repeat it over and over again."
Although "not anti-technology," the hospital group could not afford making a large initial investment in IT for a telestroke program, Livesay says. "We've accomplished what we've done with a laptop, a Webcam and a connection with web services." Eventually, a telestroke program is about to produce its own "downstream revenue" because it has generated patients in need who can be served in other areas, Livesay says.
Such a community-based telestroke network that maximizes downstream revenue opportunities fosters physician relationships under a sustainable neurological business model, says Rob Fisher, RN, MBA, vice-president of cardiovascular center of excellence and neuroscience center of excellence at the St. John Providence Health System in Warren, MI.
"It's a critical factor in that relationship to have transparency," Fisher says.
As Gienna Shaw wrote in HealthLeaders Media, "if there's one technology that has the potential to fundamentally change access to healthcare in rural areas, it's surely teleheath."
That's backed by the 2011 HealthLeaders Media Industry Survey of technology leaders, which found 46% of respondents already have one or more telemedicine programs in place. Another 41% say they'll have one in place in one to five years.
St. John Providence is proposing a comanagement structure in telestroke to help guide the program as it expands its research, geographic reach and leverages its brand, Fisher says. Essentially, physicians would be given the ability to design and manage 'the most operationally efficient clinical program for care of their service line's patients across the hospital," he adds.
In developing telestroke programs, it is important to consider legal ramifications. "Unfortunately, much of medicine is defensive, it's to keep our physicians out of court," says Phil Pomeroy, vice president, neurosciences, at Barrow Neurological Institute. "Unless it changes dramatically, (we) are still locked in a very traditional and very expensive (system).
Even with telehealth our physicians who are engaged in that process have a little uneasiness. As they hand the baton (to another physician), there's 'what if and things go south, and all of a sudden everyone gets a little clammy, what are the risks and the legal liabilities? It's going to be a real challenge; it's very squishy."
Despite the risks, Pitt notes that telestroke and other telehealth programs "prompt dialogue outside the walls of traditional institutions." Tele-medicine offers the opportunity to "follow that patient as they pass through their lives."
Joseph R. Betancourt, MD, MPH, recalls when he was 7 years old in the 1970s he helped his Puerto Rican grandmother interpret in English at a doctor's office in New York City.
During her session with the physician, his grandmother seemed pleased and appeared to understand the doctor's intent. Later, she observed, "I'm not sure what the doctor said and I'm not going to do it anyway,'' Betancourt recalled, evoking laughter from his audience last month at an American Hospital Association meeting in Washington D.C.
Betancourt, director of The Disparities Solutions Center and senior scientist for the Institute for Health Policy, and director of multicultural education for Massachusetts General Hospital, noted that some physicians feel if they "speak loudly enough and slowly enough" they are properly communicating to patients. More laughter.
It may be loud, he says, but it's not enough. And, ultimately, it's not funny.
Under healthcare reform, millions of currently uninsured will be become part of the insured, and many will be seeking care in physician offices instead of emergency departments.
At least 50 million Americans were without health insurance in 2009, according to the Census Bureau. About 32 % of Hispanics, 21% African-Americans, 17% Asian, and 15% whites were listed as uninsured, the bureau states.
To make healthcare reform work and more welcoming to the newly insured, it is important that the healthcare system makes significant efforts to overcome racial and ethnic disparities in care. Otherwise, how can we progress?
Yet, as healthcare reform increases reimbursements for quality, with such programs as Accountable Care Organizations, hospitals and physicians aren't moving fast enough to meet the challenges of diversity in their quality improvement programs, says Betancourt.
There are "many sources that contribute to disparities, there is no one suspect; no one solution," Betancourt said at the AHA meeting.
"Hospitals have so many things to do. The jury has been mixed on it – do we collect race and ethnicity data? There's a lot of devil in the details. If you don't collect it, you certainly aren't going to link it to quality." As the Joint Commission pursues improvement of quality issues, Betancourt says, "you'll have early adopters and progressive (hospitals) to collect racial and ethnicity data, but others will wait until it is either forced upon them or incentivized."
Earlier this week, Betancourt and I talked more about his comments before the AHA. He says it's important that hospitals – and physicians – begin now to address disparity issues if they haven't done so already.
"From the standpoint of hospitals – it's really critical that they begin to measure quality by race and ethnicity. And to do that they will need to create race and ethnicity data, and that links to the communication piece," Betancourt says. "If you look at race and ethnicity, you can look at where the gaps are and where you might intervene."
"I think what we are seeing now is a sporadic collection of this information," Betancourt adds. "Even those (hospitals) that are collecting race and ethnicity data, for example, few are linking it to quality measurement."
Certainly, there have been many reports over the years, raising the question of disparity issues and what needs to be done, including the Institute of Medicine's report, Unequal Treatment,' are a treasure trove of reports over the years, on the disparity issue.
The Centers for Disease Control and Prevention recently released "Research to Practice: Building Our Understanding," a series of reports that focuses on health communication practices that address topics ranging the most effective ways to communicate with the Hispanic and Latino communities to helping users apply effective evaluation strategies, as my colleague Alexandra Wilson Pecci wrote about last month.
Communication problems are most frequently the cause of serious adverse events, compromised by language barriers, cultural differences, and low health literacy. The result is increased length of stays, Betancourt says.
Because of communication difficulties, providers may tend to order expensive tests such as CT scans for conditions that could otherwise be diagnosed, Betancourt says. Minority populations are more likely to be readmitted for certain chronic conditions such as congestive heart failure than their white counterparts, he adds.
Dealing with communication and disparities issues begins at the C-suite, Betancourt says. The Disparities Solutions Center, which Betancourt heads, which is dedicated to development and implementation of to eliminate racial and ethnic disparities, and provides leadership training to do so. The DSC opened in 2005, with initial funding from Massachusetts General Hospital and the Partners Health Care system, and is affiliated with MGH and the Harvard Medical School's department of medicine. It issued a guide for hospital leaders about disparity issues, such as diabetes management, and highlights practices to address the issues.
"We have a committed program," he says of Massachusetts General Hospital. " We have a guilty-'til-proven-innocent mentality regarding diversity issues. It's not about blame, but knowing there are gaps to fill."
The Massachusetts General Hospital established a disparities committee in 2002 after the IOM issued its report documenting the disparity problem nationally. According to Betancourt, the MGH committee continues to identify and address disparity issues "wherever they may exist" at the hospital. The committee receives information from subcommittees that target "experience, education and awareness" involving racial and ethnic issues, he says. On a regular basis, the committee's planning and findings are presented to the MGH board, executive council and other hospital leadership officials. Their reports range from non-adherence to policies, educational programs and data collection issues.
The hospital established cross-cultural training as well as interactive learning programs to allow them to "provide quality to patients of diverse cultural backgrounds," Betancourt says.
As a result, the hospital program resulted in significant awareness improvements among physicians after training 3,000 front line staff.
"If a certain group of diabetic patients are doing less well, maybe you can find some explanation, maybe it's a [literacy] issue, maybe it's a cultural issue, and then you can target interventions to meet those patient needs," Betancourt says.
Coaching programs and patient navigators who are important tools to overcome racial and disparity issues, he says. While a doctor visit may be about 15 minutes, the coach may then spend an hour with a patient, Betancourt says.
In Chelsea, MA, two miles from Massachusetts General Hospital, hospital officials found differences in diabetes control in Latino and white populations. While 24% of the white population had diabetes, 37% of Latinos had it, he says. To improve patient conditions, a coaching program was established in which a doctor and coach worked in tandem to address the problems, Betancourt says.
Too often, physicians don't acknowledge they need help in assessing racial or ethnic disparity issues. Some may say, "I only have 15 minutes to see a patient and 'how can I get to all these cultural issues?"
"This is really about excellence in clinical care and really [about being] a more effective clinician," Betancourt says, referring to guidelines to help physicians and hospitals address disparity concerns. "And as much as we can get that message out, we can get greater provider buy-in."
Unfortunately, he says, some things don't change fast enough.
"We have a one-size-fits-all mentality and we leave a lot of people out of the way in which we deliver care," he says. "We need to figure out ways to improve quality, how to customize our services to meet the needs of a diverse population," he says. "It doesn't have to be minorities. It can be the elderly." For physicians and hospitals, "that's sometimes challenging and to overcome that is going to distinguish the leaders from the followers," Betancourt says.
In the 1970 movie "Love Story" a now-classic line was born: "Love means never having to say you're sorry."
Well, celluloid love isn't medicine, and "I'm sorry" has become the new iconic line in legislation being adopted in states across the nation to give providers greater protection for medical errors against lawsuits.
The latest one was last week when Gov. Rick Snyder of Michigan signed an "I'm sorry" bill. At least 36 states have adopted laws that generally bar physicians' expressions of compassion or sympathy about pain, suffering, or the death of a patient to a patient or family as an admission of liability in medical malpractice suits.
Top officials of the American Medical Association and the American Hospital Association told me that they support the legislation but note that it must be worked within an overall framework of tort reform.
Are we so litigious that we have to legislate feelings of compassion, or just being honest? I guess we are. I'm sorry it has come to this. Saying "I'm sorry" has its practical impact, apparently. The University of Michigan Health System adopted a policy of investigating adverse events in 2002, and included the apology strategy. The health system says it cut litigation costs in half and new claims declined by than 40%.
So, in part, saying "I'm sorry" works. "It's amazing you actually have to pass a law to say you are sorry," saysKenneth Elmassian, DO, an anesthesiologist and member of the board of directors of the Michigan State Medical Society. He also is on the board of the American Society of Anesthesiologists.
When my dad died of cancer in a hospital 15 years ago, my mother felt everyone seemed so cold, so sterile. There were expressions of sympathy, but it seemed perfunctory. In any event, she was not planning to race to an attorney's office to file some malpractice suit. Everyone did what he or she could for my dad. Blame was not in the family's lexicon following my dad's death. Sorrow was.
In Michigan, there is a broad coalition of support for the "I'm sorry" measure, including a group of medical malpractice lawyers. The legislation has an enabling quality for patients as well as physicians, Elmassian says. "Compassion expressed at the time of the event provides closure for families. That's the key point," Elmassian says. "Many times, they want answers for what happened."
Cecil B. Wilson, MD, president of the American Medical Association, said in an interview with HealthLeaders Media that the AMA sees the "I'm Sorry" legislation as "potentially viable." But, he says such measures must be incorporated with other aspects of tort reform to crack down on malpractice litigation, such as medical courts, expert certification procedures and "safe harbors for physicians who practice" under scientific guidelines.
"We think all these things need to be tested to see if it helps us with the challenges we have in medical liability that we think has run amok," Wilson said. "Just the apology itself has to be part of a bigger system to be helpful. The reality is that the current system creates so much animosity." Generally, many lawyers discourage physicians from apologizing, and "certainly most insurers discourage them from apologizing for fear it would hurt them in court," Wilson said.
The overall liability reform is necessary, in part, to "decrease this atmosphere of animosity "and "defensive medicine," Wilson said. "Physicians fear being hauled into court."
Nancy Foster, vice-president for quality and patient safety policy for the American Hospital Association, says that the "I am Sorry" legislation is a step forward in dealing with malpractice issues.
"We believe it is critically important that the physician and hospital maintain an open avenue of communication with patient or patient's family when the patient has been injured due to an unfortunate medical error," Foster said in an interview. "And so things that get in the way of that communication like fear of litigation are not helpful. The fact that someone says I'm sorry shouldn't be held against them in a court of law."
So here we are, at the beginning of healthcare reform, ready to dive in, and one of the prized goals is to reduce medical errors to begin with, enhance quality, and hopefully get rid of ridiculous lawsuits that raise the expense bar in an already inflated healthcare cost system.
As for saying "I'm sorry," that may be a step in the right direction, for medicine. Eventually, maybe healthcare won't need the line anymore.
Even Ryan O'Neal joked about the famous Love Story line in the 1972 movie, "What's Up Doc?" After hearing Barbra Streisand say, "Love means never having to say you're sorry, O'Neal said: "That's the dumbest thing I ever heard."
When I was a little boy, my Italian-American grandmother would say, "Joseph, Joseph you are giving me agita," a slang for heartburn in Italian, usually after my friends and I broke some window playing baseball on the street.
The windows are cracking at the American College of Surgeons and the organization has a huge case of agita over a Valentine’s Day debacle involving its editor-in-chief's ill-chosen words in an opinion piece published in Surgery News, the official newspaper of the ACS.
No medicine is going to cure this heartburn anytime soon. The controversy and its fallout have put the spotlight on ACS’s virtually do-nothing board.
The debacle has to do with incendiary comments made by editor Lazar Greenfield, MD, who suggested in a Valentine’s Day piece entitled, "Gut Feeling" that unprotected sex enhances women’s moods.
Greenfield’s opinion piece attempted to highlight certain scientific findings about mating and reproduction. "As far as humans are concerned, you may think you know all about sexual signals, but you’d be surprised by new findings," he wrote in the Valentine’s Day piece. I'll spare you the details, but you can read his editorial here.
Greenfield, 78, resigned Sunday in the wake of the controversy. He also withdrew as president-elect of the ACS. Greenfield is a professor emeritus at the University of Michigan Medical School.
Greenfield’s comments make a mockery of unprotected sex, are demeaning to women, the board, and to Greenfield himself. Not everyone agrees. Can’t you take a joke, some ask. Others say, Greenfield is a distinguished surgeon, be respectful.
But seriously, didn’t the board ever hear of a red pen? Allowing Greenfield’s comments into print to begin with makes one wonder about the ACS’s editorial review process, if there was any. Did Greenfield have carte blanche to say what he pleased?
The board took action only after the fact. The entire edition of the publication that included the editorial was withdrawn. By then, there was outrage all around.
Greenfield has insisted that he meant to be lighthearted. "I accepted responsibility for using scientific material in a light-hearted way to review new biochemical findings in sexuality," Greenfield said in an apology. "These findings show the remarkable way nature has promoted strong bonding between men and women, a gift rather than something demeaning."
Greenfield noted that he wrote the editorial as an "opinion piece written for a monthly throw-away newspaper, not a scientific journal," although his report was supported scientifically. In an email to the Detroit Free Press and some other media, Greenfield defended his comments in the wake of his resignation, saying his intent was mostly "light-hearted comment."
"The reports surrounding my resignation as president-elect of the American College of Surgeons lead readers to conclude that I represent an old-guard generation that represses women in surgery," Greenfield wrote. "Since nothing could be further from the truth. I can no longer remain silent in an attempt to protect the organization."
As some of Greenfield’s supporters have said, over the years he encouraged many women surgeons in their careers. That’s nice. But after reading his Valentine’s Day massacre of prose, you can’t help wonder about his current state of mind about women in our society.
Dr. Colleen Brophy, a professor of surgery at Vanderbilt University, told The New York Timesthat she was so angered by the Lazar's column and the board’s slow response that she resigned. "I have two teen-age daughters," Brophy told the paper. "What bothered me most was that a member of our leadership could advocate for unprotected sex. Even if he meant it as a joke, the way he wrote it came across as blatant. And it's not even an appropriate joke."
In light of all this, the ACS board's reaction seemed pretty timid. A comment posted on the New York Times site, attributed to the executive office of the ACS, reads: "The American College of Surgeons deeply regrets the offense taken to Dr. Greenfield’s editorial about Valentine’s Day. The Board of Regents has taken the matter under advisement and is working collaboratively to determine the best course of action."
A separate statement issued by Carlos A. Pellegrini, MD, FACS, chair of the board of regents, L.D. Britt, MD, FACS, president and David B. Hoyt, MD, FACS, executive director of the ACS, reads, "The contributions Dr. Greenfield has made to the field of surgery, including the invention of the Greenfield Filter, cannot be overstated," said the statement.
"We wish to honor Dr. Greenfield and celebrate his inestimable contributions to the College and the surgical community," they added. "We also know that at this critical juncture for surgery and health care in America, it is important that the American College of Surgeons not be distracted by any issues that would diminish its focus on improving care of the surgical patient."
Beyond that statement, the Board has not responded to my request for further comment.
Are you kidding? The distraction is front and center. That’s my gut feeling.
If the move toward electronic medical records were a race, the Valley Baptist Health System was ready to lap competitors several years ago. The system began looking into electronic medical records in 2008. James E. Eastham, president and CEO of the 800-bed hospital system in Harlingen, TX, was pretty excited about it then, remembering how everyone in the system was getting involved, and he saw physicians as part of the solution.
Within a short period of time, however, plans came to a sudden and costly halt. Physician "resistance" was part of the problem, Eastham recalls.
"We were excited about going to the EMR and spent a lot of time and resources and a lot of money. We wanted to be early adopters," Eastham says, recalling what turned out to be a humbling EMR transition, which is always a good lesson to everyone, physicians included.
"We got off to a rocky start. It wasn't easy, although we had the best of intentions," Eastham adds.
At Eastham's hospital system, the initial projected cost to implement its IT system was $18 million. "We knew we had to make it as user-friendly as possible," he recalls. The hospital's internal IT team set up the system and was assigned to bring physicians on board. The system was all set up. Then, little by little, flaws were exposed. The system wasn't as "user-friendly" as initially thought. Physicians had trouble logging on. There was mechanical resistance, and physician resistance.
"It was a big transition and [there were] big expectations," he says. "There was just so much resistance from the medical staff. It wasn't working for them. Using the internal IT staff wasn't working," Eastham says. "We probably had to too many consultants coming in; we didn't have the depth internally. We hired a lot of different consultants and that sent the costs up.
The physician relationship with electronic medical records continues to evolve. The hospital system was so concerned with ensuring that physicians were hooked up to the system, that the hospital neglected one of its most crucial elements, the computer system. "We should have refurbished all the computers on the floor. It wasn't as operational as it should have been," Eastham says.
Eastham's early experience is reflected by physician concerns elsewhere. The Medical Group Management Association released findings this month that illustrate some of the obstacles for physicians in moving forward with EMRs or EHR (electronic health records). The MGMA survey includes data related to physicians' own productivity as well as participation in the government's meaningful use incentives and overall costs.
While most (80.1%) medical practices surveyed who already adopted electronic medical records said they intend to participate in the meaningful use incentives available through the HITECH Act, only 13.6% indicated they are able to meet the 15 core criteria for eligibility to receive incentive payments. Interest in qualifying for EHR incentives was also strong among the respondents who now use paper medical records, with 28.8 % indicating they were in the process of selecting an EHR system, according to MGMA.
Most electronic medical record owners – 72% - said they are satisfied with their overall systems. They were split over their ability to increase physician productivity: 26% reported that productivity had increased; 20.6% indicated it had decreased, with 42.9% reporting there was no change in productivity after launching an EHR system.
About 38.4% of electronic medical record users said total practice operating costs increased, while 25.9% say the costs decreased; 25.7% reported no change.
The government's "EHR incentive program seeks to address implementation costs, a critical barrier to medical groups' adoption of EHRs," MGMA President and CEO William F. Jessee, MD said in a statement, but it is "clear that groups face significant optimization challenges."
"We are hopeful that as the future stages of the incentive program are developed, the government will take into account the difficulties medical groups currently face in meeting the meaningful use requirements," Jessee said.
Many physician leaders are hopeful for the federal incentive funds. funds the HealthLeaders Media Industry Survey 2011 shows that 44% of physician leaders plan to take advantage of federal funds to "install or upgrade" an EHR; with another 13% saying they won't be eligible to receive funds until after 2011. About 24% say it was "too early to tell" and 3% say physicians weren't on board.
Health leaders certainly know about frustrations in starting up EMRs. Steve Johnson, CEO of Susquehanna Health in Williamsport, PA, told the American Hospital Association representatives at their membership meeting in Washington DC this week about some of the problems he faced in beginning an EMR system.
His hospital system relied on a chief medical information officer to handle all the issues, says Johnson. The rest of the staff, however, depended too much on her, too, Johnson says. The consistent refrain of medical and clinical staff: "I'm not going to deal with IT, Dr. Jane will do it," he adds. They figured: "She'll take care of it. She'll do it. That was the mantra from the medical staff to a lot of the clinical staff," he recalls.
The chief medical information officer left her post, and the rest of the hospital system leadership were left in the dark as far as EMRs were concerned, Johnson says. Hospital leadership, however, working with physicians, found ways to improve their situation and aren't looking back. After the leadership left, Johnson says a chief medical officer began running the system, and a physician champion was identified to help and "all of a sudden there was engagement. It is something we wish we [had] started [with] right off the bat."
Generally, according to MGMA, physician practice ownership has influenced EHR implementation and optimization. "Interestingly, independent medical practices were more likely to have a fully implemented and optimized EMR than their peers owned by hospital systems," the MGMA report states.
The Inland Northwest Health system found a way to engage physicians while implementing a common hospital information system across 34 mostly independent hospitals in Washington state and Idaho. The result has been a regional data repository system with standardized data selection, under a Meditech Information Technology system of San Antonio, TX, with improved efficiency and lowered costs, according to Thomas Fitz, CEO of Northwest Health Services in Spokane, WA.
As the health system began implementing the regional data collection service, the concerns of physicians were paramount, says Fitz. When the program was launched, 100 doctors wanted to meet him. He was reluctant. To Fitz's surprise, the physicians told how they wanted to become integrated into a data collection system, relating their own "horror stories" of hundreds of thousands of dollars lost in investments, "systems down 18% of the time" and staffs simply tiring of trying to manage their EMR systems.
As for Eastham, he refused to give up on EMR, and retrenched, hiring an outside consultant, Anthelio Healthcare Solutions, of Dallas, TX, which specifically worked directly with staff, educating them about the new system, and, most importantly, spending time with them. If physicians had a "problem," the specialists visited them, Eastham says.
"There was a SWAT team, and (computer) fixes were made on the spot. It was costly but you can't have our medical staff not accessing the system," Eastham says. "We developed a schedule for training; they were very time-consuming sessions." At general staff meetings, the consultants would "walk (the physicians) through the system. Once they got used to it, all the bugs were worked out,"Eastham says, "And as those got more familiar with it, they loved it."
The government's ACO bus has finally arrived. Its 429 pages of proposed guidelines having spilled out, all of healthcare is now scampering to read the lines and between them.
Under the accountable care organization model, there are many participants. But whether there will be enough room for physicians to participate to their liking, or whether ACO is a new form of HMO are a couple of the many questions in the great debate surrounding the release of the proposed rules.
Overall, there are mixed reviews on the Centers for Medicare & Medicaid Services proposed ruleproposed ACO regulations released last week.
Donald Berwick, the CMS administrator, and Kathleen Sibelius, the head of the HHS, say the model could save millions of dollars in Medicare funds and improve care for Medicare patients, and that they shouldn't be equated with HMOs, not at all.
Along with the shadow of the HMOs – seriously, the critics whisper HMOs all the time, and sometimes mention "HMOs on steroids" – what's in store for physicians?
Roland Goertz, MD, MBA, FAAFP, president of the board of directors of the American Academy of Family Physicians, recalls being a VP of medical affairs at an integrated system years ago and recalls when managed care was moving "full steam ahead" in the 1980s and 1990s, and "some of the factors that drove it were similar to today."
HMOs are not ACOS, no way, he says, but healthcare needs to fix cost as a driving force in the care delivery model, with physicians in the mix.
Like most other physician groups, the American Academy of Family Physicians is studying the proposed CMS regulations regarding ACOs. While there are some areas of concern that have been addressed, others have not yet been determined, Goertz says.
Moreover, the group is urging its physician members to evaluate the potential for ACOs for physician groups to set up their own practices within them. Goertz acknowledges, however, the AAFP leadership is extremely "cautious" because of anti-trust regulations. The ACCFP membership includes 65,000 family physicians, roughly 84% of all family practioners in the country. About half its members are in small or medium-size practices.
"We are very keen in trying to urge physicians to set themselves up to form ACOs, so that the only ACO model is not driven by hospitals; not that that's bad, but we think should be; urging our members consider in a regionalized way forming either IPAs (independent practice association) or optional formats that the rules would allow," Goertz says. "Physician groups might structure themselves to also be an ACO. We hope that indeed happens.
"We do believe and we have said a strong primary care basis is going to be very important for an ACO to function," he says. "The patient-centered medical home in the neighborhood of other specialists and other elements of healthcare delivery is one of the only models of healthcare reformation that offers an option with provable demonstration projects that bend the cost curve while maintaining quality and good patient care."
As the academy sees it, however, solo and small practioners not only enable participation in the ACOs, but also have the option for an "opt out," Goertz says.
"We had some real concerns about how the rules would be written in restricting participation of solo practioners or small group practices within an ACO," Goertz says. "It appears the use rules do allow participation, and indeed, do allow an opt-out, if indeed a practice decides they'd just rather stay traditional. How long that would be allowed, I'm not sure. That's part of some of the questions that we will ask."
"The other thing that we had concerns about, and will continue to have concerns [about]– but appears to be addressed, [is that] there is a required physician-directed quality assurance and improvement process built within any proposed AMO format. Embedded within that set of rules is a 75% ACO leadership or governance being represented by clinical or administrative physicians," Goertz said. "We think a lot of physician organizations were concerned that this ACO formation might be viewed by less healthcare oriented businesses as an opportunity for less healthcare minded entities to get into the fray, to set up governances and structures that weren't necessarily going to be patient-focused and care-driven. We are pleased with those aspects.
However, Goertz says there is a "two-edged sword" in the formation of the ACOs as outlined by CMS, although targeting improved patient care and efficiency outcomes, "has a bit of variability" that still needs to be determined through a stricter set of guidelines. "Without a more restricted set of guidelines you are going to have a bit of variability that is going to have to be tolerated for awhile," he says.
Another major area of concern for physicians involves in the formation of ACOs, in capital requirements and anti-trust issues, outlined in the HHS document as well as a proposed ACO anti-trust enforcement policy from the Department of Justice and the Federal Trade Commission.
"Significant barriers" must be addressed, Jeremy A. Lazarus, MD, speaker for the American Medical Association House of Delegates, said in a statement following release of the proposed rule, including the large capital requirements to fund an ACO and make required changes.
The capital requirements for ACOs might be too high for many physicians. In a December, 2009 letter to Berwick, the AMA's executive vice president, Michael D. Maves, MD, MBA, wrote that the CMS should only establish requirements for ACOs that require large capital investments if it provides a financing mechanism to enable physician practices to make those investments.
Maves suggested that the government create loan, loan guarantee, and technical assistance programs to help small physician practices make the investments needed to become ACOs. Taking those actions "will significantly reduce the need for upfront investment, as well as reduce risks and delays in recouping those investments," Maves wrote.
Taking the actions above will significantly reduce the need for upfront investment, as well as reduce risks and delays in recouping those investments, according to Maves.
As for anti-trust issues, the AMA suggested that the government should create explicit safe-harbors from antitrust enforcement and waivers of the civil monetary penalty statute "so that small, independent physician practices can work with each other and collaborate with hospitals and other providers to deliver coordinated care for both Medicare beneficiaries and commercially-insured patients."
Kester Freeman, former CEO, Palmetto Health, wrote in a blog, after the HHS released the proposed ACO rules, "While steps are being taken to avoid antitrust issues, I feel all of these details need to be resolved ahead of time so that hospitals and physician groups can feel confident they can collaborate freely," he says. "The antitrust regulations need to be in place before January 2012 so there is clarity for all involved."
Indeed, the anti-trust issues and complex, making his organization tentative, at best, about the steps ahead, says Goertz.
"The previous model of healthcare arrangement, unfortunately, did not foster organizations of physicians getting together in the same way other organizations in healthcare would get together because of anti-trust rules," Goertz says. "This is one of the rules we are looking at very closely. We are very careful not stepping over the line right now."
"We are in favor of not having in the future a solely fee-for-service payment; we are advocating a blended payment," says Goertz. "We believe ACOs will have to move in that direction. But we have concerns that if we put specifics of a blended model, we would be accused of antitrust activities, in urging all our members to contract this way or that way."
"There are a lot of restrictions we need to sort out to see if there is some leeway, without harming free trade – and at the same time (giving) family physicians their best options."
Hospital leadership at the MemorialCare Health System in Southern California use a term to describe their plans for efficiency, physician alignment, and improved patient outcome in orthopedic care: Cruising to Recovery.
The phrase signifies not only the locale of the hospital system, not far from the ocean, but also its revamped method of care for orthopedic patients. Hospital leaders discussed the changes Tuesday at a HealthLeaders Media Rounds event, "Orthopedic Leadership Strategies: Engage, Measure and Perform" at the Orange Coast Memorial Medical Center in Fountain Valley, CA.
They discussed the development of a joint replacement center, with a patient-centered focus that was the result of many internal system changes within the system. Using Lean principles, hospital officials also developed patient-education coaching models to attain what they term better outcomes and efficiencies, while focusing on improved physician leadership strategies for improved alignment and engagement.
The hospital's physician structure has been and continues to evolve in importance. "Our ability to partner closely with physicians is critical as we prepare for healthcare reform, with stronger partnerships, shared decision-making and innovative leadership models," says Marcia Manker, CEO of the Orange Coast Memorial Medical Center.
Hospital collaboration is especially important with the MemorialCare Physician Society, which consists of more than 2,000 physicians, developed in 1996, and IPAs (independent practice association). "It's the foundation of our physician alignment that is critical to meet the needs of our doctors and the changing face of our delivery system," Manker says. "The physician society teams up with our employees to drive clinical standards in performance resulting in exceptional outcomes."
California's restrictions on ownership of medical practices and systems allow the medical foundation model for "greater alignment and shared efficiencies," Manker says. The MemorialCare Health System also includes the Long Beach Memorial Medical Center, Miller Children's Hospital, and the Saddleback Memorial Medical Centers in Laguna Hills and San Clemente.
As hospital officials evaluated changes in care, orthopedics was identified as an appropriate service line for Lean approaches due to the complexity of patient flow, as well as the high cost and significant volume, whether it was hip, knee, bilateral, or other focus, says Pamela Chevreaux, vice president, ambulatory services, for the Long Beach Memorial Medical Center.
Moreover, while there was a dedicated staff for orthopedic surgery, it was not specifically for joint replacement, Chevreaux says.
A major change involved revising focus to patient-centered care, says Douglas Garland, MD, medical director of the MemorialCare Joint Replacement Center and co-chair of the orthopedics, neuroscience and rehabilitation units at Long Beach Memorial Medical Center. The hospital system's previous approach was not considered patient-centered, and the care team was not united under a common philosophy of care, says Garland. As a result, it lacked focus and effort on defined outcomes. For instance, post-operative goals, he says, were considered "clinician-centric, not patient-centric."
Making a swath of changes, including implementing a Lean system, Chevreaux says they were able to improve procedures for patients prior to surgery by expanding education programs, streamline patient interactions, while establishing a family and patient selected "coach" used throughout the process. Patients also were assigned a joint center coordinator to review their procedures.
Developing a total joint center, says Garland, "is not as easy as you think. It's very difficult. First you have to have identifiable goals and you have to select the proper leaders."
As far as Garland is concerned, partnership with orthopedic surgeons became a key element in the overall changes, beginning with sharing data. Changes within the system resulted in direct improvement in patient care, he says.
Under a previous system, patients who had orthopedic surgery would not get out of bed until the day after surgery, would stay in the hospital for at least four days and probably be off work for three months, and would take at least six weeks to get into a car to drive. There was also uncertainty for the patient about obtaining physical therapy.
The changes allowed for a streamlined approach where planning occurred in plenty of time before surgery that allowed patients time to know their exercises, discuss local instead of general anesthesia, had a single point of contact for questions, had scheduled surgery, therapy, and was taught to get in and out of a car safely. A guidebook issued to the patients allows them to monitor their exercise program.
A joint coordinator "is the patient's advocate. If there is a nursing problem, they will tell her. If (the patients) they don't like the physician, or not happy with the therapist, they will tell (the coordinator). It is really truly value added and empowerment at that point of service," Garland says.
Increasing education for the patient has reduced "fear and confusion" among patients, Garland says. Improved collaboration among physicians and staff has reduced the possibility of turf wars, he adds.
The joint replacement procedure changes have resulted in significant improvements to patient care as well as ROI, according to Chevreaux.
For instance, she says, the system has seen decreased length of stays, from 4.35 to 2.96 days; improved distances that the patients are walking, as well as improvements in overall recovery. The number of patients sent directly home increased from 12% to 81%. As for costs, implant expenses were reduced lower than the national average, and the number of private pay patients increased 31%, she says.
"It is truly a paradigm shift how we are delivering health and wellness," Chevreaux says.
If accountable care organizations are the next big thing in healthcare, their cousin has been around longer, and probably has more staying power: Multidiscipline approaches of care. But those approaches may only be successful if physicians can leave their egos behind.
Klaus Thaler, MD, a minimally invasive surgery specialist for Hudson Valley Hospital Center in Cortlandt Manor, NY, is a prime advocate of multidisciplinary care at his hospital. He also serves as a team "captain" to help other physicians work together under the framework of multidisciplinary care.
Thaler, who has been at Hudson Valley for about a year and a half, is excited about the growing focus on multiple disciplinary teams; whether it's bringing "multidisciplinary surgical and non-surgical disciplines" together, as he puts it, or radiation therapists working with other specialists to improve patient outcomes.
Thaler's specialties are in digestive and minimally invasive surgery, and he joined Hudson Valley Hospital Center in July 2010 to create a "center of excellence" in those specialties. Previously, he served at the University of Missouri as director of gastro-intestinal surgery and co-chair of the robotic surgery programs. He is working in an emerging field of natural orifice surgery, aimed at reducing scarring and pain, and speeding recovery.
In a recent conversation, Thaler discussed the multidisciplinary approaches positively, and smoothly. And then I asked him about the process of putting teams of physicians together. Despite all the talk about hospitals moving in the direction of multidisciplinary teams, in reality, the process is extremely difficult, Thaler says.
"It's a cultural change, it's a huge change," Thayer says, especially for the physicians. "It is a cultural change to accept the notion that you as a physician are not in the center of the care process. It's the patient and everything is being done that is necessary to optimize the patient's well-being."
So, multidisciplinary techniques are definitely part of the framework of care, but ego is part of the potential for disarray.
The physician conflicts that underlie the potential good of multidisciplinary approaches were addressed in a 2009 book by Atul Gawande, "The Checklist Manifesto – How to Get Things Right." Gawande is a physician and writer for The New Yorker.
"We in medicine continue to exist in a system created in the Master Builder era -- a system in which a Lone Master Physician with a prescription pad, an operating room, and a few people to follow his lead, plans and executes the entirety of care for a patient from diagnosis through treatment," Gawande writes.
"We've been slow to adapt to the reality that, for example, a third of patients have at least 10 specialist physicians actively involved in their care by their last year of life and probably a score more persons, ranging from nurse practioners and physician assistants to pharmacists and home medical aids, " Gawande adds. "And the evidence of how slow we've been to adapt is the extraordinarily high rate of which care for patients is duplicated or flawed or completely uncoordinated."
Obviously, there are no guarantees in the multidisciplinary approaches, and even the tiniest slips may occur, and could portend disaster. A few months ago, as I lay in bed waiting for an appendectomy, I saw a team of physicians approach patients to discuss what was anticipated during surgery. I could see and hear the team moving from one patient to another as they got closer to me.
Ah, I thought, multidisciplinary care at its best. The thought changed quickly. As the physicians reached the bed of a patient separated by a screen from mine, I heard the team of physicians explain what was expected, as they described the condition and details about the patient's condition and needs.
The only problem was they were talking about my condition, not the other patient's.
Oops, the physicians acknowledged: they realized they were speaking about my condition to the other patient. There were apologies all around.
The process is not without flaws, but as Thaler points out, the multidisciplinary approaches are the best way to improve patient care and minimize malfunctions. A physician trained in Austria, Thaler says he began embracing the multidisciplinary concept in the 1990s. A proper compensation plan to enhance the multidisciplinary work of physicians is essential, he says, and a physician's ego can be translated into something positive, delivering the "fortitude that makes it work"
Aside from the compensation, "it is most important to have a 'physician champion' who shares the vision and mission to do that," Thaler says. Such a leader is "an important factor to organize groups of physicians to develop their care plans, he says.
A physician champion is so important he or she should be specifically appointed within a hospital structure, according to Thaler. "If you don't have a clear appointment in such a position (that person) will most likely not be fully accepted," he says. The physician champion "should have the experience and knowledge and background that other physicians accept and look up to, and accept that person as an expert in the field," Thaler adds.
I thought of Thaler's comments about the need for proper protocols in establishing a physician team as I pondered the checklist phenomenon.
Perhaps the checklist idea should be expanded – something like a Physician Champion Checklist – to not only analyze clinical procedures, but to evaluate the attitudes of a physician team – so potential ego problems, for instance, can be checked at the door.
Sounds good, no? The decades long-debate over how long resident physicians should keep working per shift, and how much rest they need, continues, like a long-running dream. These are major questions being considered by medical directors of residency programs as new regulations come online in July.
The Accreditation Council for Graduate Medical Education (ACGME) is preparing to launch regulations that say first-year physician residents must work no longer than 16 consecutive hours. The plan includes provisions to replace standards that now allow interns to work 24 consecutive hours.
The ACGME, which is promulgating the regulations, is a non-profit organization that oversees training programs for resident physicians and is responsible for regulating and enforcing resident physician work hours, and accreditation of post-MD medical training programs.
While the ACGME insists it has made inroads into the fatigue issue and related patient safety concerns, physician residency program directors suggest in a new survey they aren't exactly pleased with the plan. I don't think it will do much to allay their concerns about physician exhaustion and patient care.
Residency program directors' reactions to the ACGME duty hour recommendations "demonstrate a marked degree of concern" about physician education, according to the study by Darcy A. Reed, MD, MPH, Division of Primary Care Internal Medicine for the Mayo Clinic, and her co-authors, reported in the March issue of Mayo Clinic Proceedings. The Mayo Clinic was not associated with the survey, which was conducted after the ACGME published its recommendations.
The survey results, according to the researchers, "suggest that the new duty hour restrictions have the potential to create serious difficulties for residency programs to ensure that their trainees are meting the ACGME core competencies."
The new regulations include increased supervision during 16-hour shift maximum for first year postgraduate residents and recommendations for napping.
In the survey of resident medical directors, there was an outpouring of disagreement with the ACGME duty-hours regulations. Among the findings:
65% say it will not change resident fatigue.
6% believe it will increase fatigue.
87% say that the new ACGME recommendations will decrease residents' continuity with hospitalized patients, referring to "hand-offs" during shift changes.
78% say it will reduce efforts to coordinate patient care.
65% believe it will reduce residents' responsiveness to patient needs.
63% believe it would reduce residents' ability to effectively communicate with patients, families and other health care professionals.
Reed says it was important to question the resident medical directors about the impending regulations because "they are the ones who know what it takes to train a competent resident."
"That's why we sought their opinions," Reed says. "Some things we need to watch out for and be mindful of as the new regulations are put into place. The research isn't going to change the recommendations. That wasn't the intent. We are trying to get a sense of what program directors feel about this."
Obviously, she says, there is concern about the regulations and the impact on residents' fatigue.
Although there are new restrictions about work hours, "we don't know that the residents will necessarily sleep in the hours they aren't working," Reed says. "We assume if they are working fewer hours, they will recuperate and rest, and sleep. But that may not be. There are a lot of other factors involved: family life, level of stress, and many other activities they may be engaged in."
In addition, resident medical directors apparently are concerned that residents may simply work more over a shorter period of time, which could have a dramatic impact on patients as well as the physicians themselves, Reed says. "That's a big concern. If they reduce their hours they just might compress the same amount of work into a shorter period of time," Reed says. "Maybe they will be asked to do the same stuff but do it faster."
Another major concern is "handing off a patient to another physician at the end of a shift," she says. "We know during the hand-off, that is a high risk event. It's a vulnerable time."
How to reduce the risk of an overly tired young physician has been a point of debate for years.In the 27 years since the death of a young woman who was under the care of an apparently exhausted physician in a New York hospital, various groups have debated how much physician time should be regulated.
After the tragedy, New York State initiated changes, and in 2003, the ACGME issued "duty hour" regulations, making them mandatory for all residency programs. The ACGME says the regulations resulted in a significant reduction nationwide in duty hours and fatigue among resident physicians.
This past December, the Institute of Medicine released a report recommending strict work-hour rules. The report, ResidentDuty Hours: Enhancing Sleep, Supervision, and Safety" stated that "30 hours of continuous time awake, as is permitted and common in current resident work schedules, can work in fatigue and adjustment to the 2003 rules are needed. The ACGME' then proposedrevised standards.
Under the latest regulations being implemented, among other things, residents must have 10 hours off between duty shifts and must have eight hours free of work between duty hours.
Residents also must not be scheduled for more than six consecutive nights of night duty; have 24 hours off per 7-day period, with maximum duty hours of 80 per week, averaged over 4 weeks, with 88 hours for selected programs. Moonlighting is not permitted.
Last September, the advocacy group Public Citizen filed a petition with the Occupational Safety and Health Administration requesting that the agency regulate resident physician and subspecialty resident physician hours.
"Depending on the type of residency, physicians-in-training can work anywhere from 60 to 100 or more hours a week, sometimes without a day off for two weeks or more," the Public Citizen petition states.
Because OSHA, which is part of the Department of Labor, is charged with ensuring the safety and health of workers, it has jurisdiction over the matter, Public Citizen and other groups that joined in the petition say.
In 2002, OSHA denied a petition by Public Citizen, the Committee of Internists and Residents (CIR), and American Medical Student Association, citing the voluntary adoption of standards by ACGME.
Referring to its current petition, Sidney Wolfe, MD, director of Public Citizen's Health Research Group, said in a statement, "The dangerously excessive number of hours resident physicians are currently allowed to work is a similarly toxic exposure that OSHA has the authority to regulate and reduce in order to protect these physicians from harm."
"This is especially urgent since the current private-sector regulating organization, ACGME, has continued to abdicate its responsibility to adequately protect resident physicians," Wolfe stated.
The ACGME opposes the petition, noting: "The interests of residents and patients are served by maintaining an approach that is comprehensive and that is designed to weigh and balance in an integrated manner the full spectrum of different interests and considerations applicable to graduate medical education."
"The ACGME does that now; and the petition, if granted, would seriously disrupt the effectiveness of that system by establishing regulation of resident duty hours within the exclusive purview of the OSHA," it adds.
The current debate can be traced to the death of Libby Zion in 1984, which prompted the New York legislation to adopt regulations regulating working conditions of physicians.
The 18-year-old college freshman was admitted to New York Hospital with a high fever and mysterious jerking movements, Barron H. Lerner, MD, wrote two years ago in the New York Times.
Lerner, who was a medical student at the time, wrote that the "only doctors who had seen her were in training, that such doctors routinely worked 36-hour shifts with little or no sleep and that the attending physicians had never come into the hospital." Zion's father worked feverishly for reform, stated Lerner, a professor of medicine and public health at Columbia University Medical Center, and author of "When Illness Goes Public: Celebrity Patients and How We Look at Medicine."
After Libby Zion's death, medical students looked into their own education, and themselves, as budding physicians, in a world of intensity, and exhaustion, as they tried to retrace her care, and what went wrong.
"Would we have ordered restraints and not seen her? Would we have sent her to the intensive care unit? Would we have known about a potentially toxic interaction between drugs in her body?
Ultimately, they concluded there was a "for the grace of God go I," he wrote. "We knew what it was like to stay up for 36 hours straight, first as medical students and later as residents. It was in, a word, insanity."
In Reed's survey report, a mention was made of Libby Zion's death. It still looms large as the debate continues over physician "duty hours."