In his healthcare reform proposal to Congress last week, President Obama—under fire from the GOP for failing to address tort reform—called for including up to $50 million to fund demonstration projects to test medical malpractice case alternatives such as health courts.

While health courts are not well-known in the U.S., several countries have systems in place that could provide alternative models to jury trials in malpractice cases.

Currently, one in four dollars spent on healthcare in the U.S. pays for unnecessary tests and treatments that physicians order to keep from initially being sued, according to a new poll of the nation's physicians released last week by Jackson Healthcare and the Center for Health Transformation.

The nonpartisan group Common Good, with support from the Robert Wood Johnson Foundation, has been working with a research team at the Harvard School of Public Health to develop a proposal on how a health court system might be established. Attorney Philip K. Howard, founder and chair of Common Good, said countries such as Sweden and New Zealand have no-fault compensation programs that take "the adversarial heat away" when a medical case is presented.

Health court supporters point to a number of advantages over the current malpractice system, including:

Avoidability. The Scandinavian countries—including Sweden, Denmark, Finland, Norway, and Iceland—use the concept of "avoidability" in their health courts. Avoidability—an idea that Sweden pioneered the idea in 1975—means asking whether an injury would have occurred had proper care been provided (rather than the American negligence standard).

In house claims adjusters and expert reviewers are used to determine the total award amounts. About 40% to 45% of claims are compensated, but the overall awards tend to be moderate. Sweden's Regions Patient Injury Insurance analyzes claims data and prepares presentations of patient safety issues for hospitals and regions.

Treatment injury standard. New Zealand's health courts have evolved from the U.S. concept of negligence to a treatment injury standard. Under New Zealand's Accident Compensation Commission (ACC), an individual may qualify for treatment coverage of an injury if it occurs as a result of treatment by a registered health professional (and sometime nonregistered health professional). Overall claim rates are low—about 3,000 claims each year.

New Zealand's Injury Prevention, Rehabilitation, and Compensation Act lists the health professionals whose treatment ACC can contribute toward. The individual's health professional (physician, physiotherapist, dentist, nurse, etc.) are encouraged to help patients fill out an ACC claim form and send it in.

The ACC has a patient safety division to identify priority areas for safety improvement and to perform safety analyses using a database. The ACC writes reports and distributes them to hospitals.

To strengthen and support primary care in the future, health leaders need to consider new ways to organize providers—including primary care physicians, nurse practitioners, and physician assistants—and to expand their roles in delivering care, according to new recommendations from a group of healthcare leaders convened by the Macy Foundation.

The diverse panel, which included allopathic and osteopathic physicians from academic and general practice settings, nursing professors, nurse practitioners, physician assistants, medical school deans, academic health center executives, and representatives from health policy, government, and business, suggested that nurse practitioners and physician assistants should obtain greater roles in delivering primary care.

As part of a reformed system of primary care, healthcare leadership needs to expand the workforce beyond the scope of physicians, said Joanne Pohl, PhD, professor at the University of Michigan School of Nursing in Ann Arbor. "To put it simply, there just aren't enough of us in the field doing all the work that needs to be done," she said at a telebriefing.

The panel agreed that this means removing state and federal regulatory barriers that make it difficult for nurse practitioners and physician assistants to fully participate as primary care providers and leaders of primary care teams, Pohl said.

"Removing regulatory barriers to practice makes sense, as many of the current regulations are outdated—dating back to 30 years ago when roles were new. They lack evidence to support them, they're often costly, and they actually limit access to primary care," Pohl said.

The lack of a strong primary care system in the U.S. has had consequences for access, quality, continuity, and cost of care, according to Victor Dzau, MD, president and CEO of the Duke University Health System in Durham, NC, and Chancellor for Health Affairs at Duke University.

To make changes, it will be important to "invest" in primary care. That includes improving the infrastructure by supporting the use of electronic health records, home care, and education.

Despite what goes on at the federal level, payment reform needs to be addressed as well. "This is s tricky issue," Dzau said. "How we do that [will be met with] a long debate, but I think the issue is to rebalance—not to take away but to balance at the appropriate level support." This could help providers feel more incentivized and rewarded "for what they do."

Other recommendations from the Macy Foundation panel are:

• Medical, nursing, and other health professions schools must educate students differently for careers in primary care. They should expose students early in their education to primary care, immerse them in community primary care practice settings, teach them to work in teams, and identify effective role models for them.


• Schools should strive to attract more students into primary care by establishing programs to diversify their student bodies socioeconomically, racially, and geographically


• Academic health centers should embrace new team based primary care systems as part of their mission; they must provide interprofessional leadership by developing and implementing effective delivery models for others to replicate.

Over the years, medical imaging equipment such as X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) have played important roles in providing quality health—by quickly and quietly detecting problems ranging from brain tumors to aneurysms. And, radiation therapy has become important in providing high-quality cancer care.

But recent studies and reports linking radiation overexposure for various reasons to cancer risks, illness, and even death may be the start of a new era in the diagnostic and therapeutic uses of radiation. How can we best reap the benefits while avoiding the risks?

Late last year, in a study published in the Archives of Internal Medicine, researchers estimated that radiation from CT scans done in 2007 could cause 29,000 cancers and kill nearly 15,000 Americans. Currently, more than 70 million CT scans (which can have 50- to 500-times the radiation dose of X-rays) are given in the U.S. today annually—up from 3 million 30 years ago.

In some instances, these scans may be related to overuse or unnecessary use. For instance, a study from this month's Journal of the American College of Radiology that found that one in four MRI and CT scans were "inappropriately recommended" by doctors. The researchers found that of 459 scans at Harborview Medical Center in Seattle, 26% were considered "inappropriate."

On the therapeutic side, emerging stories—such as those presented last week at a congressional hearing on radiation benefits and risks—indicate a need for more safeguards and more staff training as well.

One of the stories presented at the Feb. 25 House hearing was that of the late Scott Jerome Parks. His father testified that Jerome-Parks accidentally had received treatments seven times more powerful than required for his tongue cancer—causing him to go blind and deaf. He eventually died. The cause: malfunctioning computer software that had not been detected by a technician.

So can more be done to address these issues? The answer is yes, of course. But, it is going to require multiple and overlapping efforts on many fronts from both the private and public sectors.

Federal assistance: The issue of overexposure received high-profile attention last month when the federal Food and Drug Administration (FDA) issued a new initiative to reduce unnecessary radiation exposure from three types of medical imaging procedure—CT, nuclear medicine studies, and fluoroscopy.

These combined procedures are considered the leading contributors to total radiation exposure in the U.S., because they use higher radiation doses than other radiographic procedures, such as standard X-rays, dental X-rays, and mammography, according to the FDA. Of concern was exposing patients to ionizing radiation a type of radiation that can increase an individual's lifetime cancer risk.

As the first prong of the initiative, FDA said it intends to issue targeted requirements for manufacturers of CT and fluoroscopic devices. These requirements address safeguards in the design of their machines and provide appropriate training to support safe use by practitioners.

For the second part of the initiative, FDA and the Centers for Medicare and Medicaid Services will work together to incorporate key quality assurance practices into the mandatory accreditation and conditions of participation survey processes for imaging facilities and hospitals.

One size does not fit all. In an ongoing campaign, the Alliance for Radiation Safety in Pediatric Imaging has reached out on behalf of especially vulnerable populations: Young children. Prior to 2001 the majority of CT imaging for children was conducted using the same techniques—and radiation levels—used for adult imaging.

Imaging teams and members of the community are encouraged to play different roles in using the "image gently" philosophy—to ensure that CT scans for children are performed at levels that are most appropriate for them.

Professional organization assistance. Last month, one professional organization dedicated to radiation oncology called for enhancing safety measures in administering medical radiation-including establishing the nation's first central database for the reporting of errors involving linear accelerators and CT scanners.

The group, the American Society for Radiation Oncology, or ASTRO, issued a six point plan designed to improve safety and quality and reduce the chances of medical errors. The group also said it is pressing for federal legislation to require national standards for radiation therapy treatment teams.

Better record keeping. Earlier this year, the National Institutes of Health announced that all of its physicians should begin recording radiation doses for patients in their medical records.

All vendors that sell imaging equipment to the clinical center will be required to "provide a routine means for radiation dose exposure to be recorded in the electronic medical record," said David A. Bluemke, MD, the study's lead author and director of Radiology and Imaging Sciences at the Clinical Center.

In addition, radiology at NIH also will require that vendors ensure radiation exposure can be tracked by patients in their own personal health records. This approach is consistent with the American College of Radiology's and Radiological Society of North America's stated recommendation that "patients should keep a record of their X-ray history."

Provider assistance. As Massachusetts General Hospital in Boston has found, electronic medical records can be used to help providers when ordering scans. Here, when a provider orders a test, he or she will get an answer back: If the test is questionable or another test might be more appropriate, physicians or other providers will get a yellow cautionary light. If a scan isn't recommended, it comes up red.

Industry alerts. The Medical Imaging & Technology Alliance (MITA) said last week that manufacturers will begin adding a color coded warning system to give healthcare providers clear warning when they are doing scans that give patients potentially dangerous doses of radiation.

The changes, which would be phased in starting this year, would require the machines to provide a yellow alert screen when the dose is higher than anticipated. The scanning devices would display a red alert warning when a patient is about to be given a dangerous dose of radiation. The system would also allow hospitals and imaging centers to set their machines to prevent these scans from happening.

Radiation and radiology have been around for so many years that we rarely give a second thought to issues such as safety and appropriateness. But for our health's sake, perhaps we should.

President Obama, saying it was neither "practical nor realistic" to go back to square one with healthcare reform as suggested by the GOP, is asking Congress to move ahead on healthcare—using a simple majority vote—and provide him with a bill that he could sign within the next few weeks.

In a speech Wednesday, Obama said the current reform legislation pending in Congress would:

• End insurance companies' practices of pre-existing condition restrictions, coverage rescissions, and caps on expenses, in addition to "big annual increases" sought by insurers annually.


• Provide better coverage and better insurance rates.


• Offer uninsured and business owners "with the same [health insurance] choices that Congress and those at the federal level" enjoy.

He said the legislation, which would cost more than $100 billion a year, would mirror what is in the Senate bill and bring costs down through with a variety of fees on device and pharmaceutical manufacturers, and additional Medicare taxes.

Senate Minority Leader Mitch McConnnell (R-KY), commenting later, said every election in November will turn into a referendum on the health reform issue. He added that the Democratic majority and administration are being "arrogant" about moving forward with the reconciliation issue, and that the bill will not pass the House.