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Saturday, August 4, 2012


Wow. Dr. Levy, throw it down!
As well intentioned and thoughtful as he is, Sanjay Gupta nonetheless misses the point in his recent New York Times op-ed “More treatment, more mistakes.”

“One place where I have seen these issues addressed is in Morbidity and Mortality, or M and M — a weekly gathering of doctors, off limits to the public, which serves in most hospitals as a forum for the discussion of mistakes, complications, deaths and unusual cases. It is a sort of quality-assurance conference where doctors hold one another accountable and learn from one another’s mistakes. They are some of the most candid and indelible meetings I have ever attended.”

“Having a consistent gathering to talk about the mistakes goes a long way toward that goal, and just about any institution, public or private, could benefit from a tradition like M and M.”

OMG. Dr. Gupta has inadvertently given us a wonderful exposition about a lack of understanding of the nature of quality and safety process improvement in hospitals. Most harm is not caused by a doctor making an error of commission, i.e., an extra test or an unnecessarily executed procedure. The number of reported adverse events from such instances is dwarfed by other forms of harm — hospital acquired infections, falls, failure to rescue, pre-39 week induced labor. Many of these are not even reportable as harm.

Dr. Gupta’s presentation reflects no knowledge about the science of process improvement. Peter Pronovost’s check list is not just a good idea. Brent James’ introduction of clinical protocols is not just a good idea. These are approaches that introduce the use of the scientific method into the clinical setting. In contrast, M&M conferences are essentially anecdotal reviews of an incredibly small number of adverse events. I would not understate their importance as teaching tools (when they are conducted in a pedagogically appropriate manner), but they do not deal with systemic problems, with near misses, with the manner in which communication fails.

As Lucien Leape [sic] and others have stated, and as Dr. Gupta makes clear in a way he certainly did not intend, the medical profession needs to have dramatically improved training in the science of process improvement as part of the undergraduate and graduate medical education curricula.
Props to The Health Care Blog, which I follow religiously.
"[T]he medical profession needs to have dramatically improved training in the science of process improvement."

I've been advocating such attention since Day One of this blog effort.

Again, Dr. Toussaint:
Governments can tweak payment systems and probably get some temporary fiscal relief. But until we focus reform efforts on where most of the money goes, which is healthcare delivery, we will remain stuck in a revolving door of near disaster and narrow escapes.To get to the point where all people have access to high-quality healthcare, affordably, we must focus our attention on how the healthcare delivery system determines costs and quality. Then we need to change that delivery model entirely.

In fact, hospitals, physicians, and nurses—all of healthcare—must change. First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence-based delivery, work that has barely begun.

There is, however, a good bit of literature on the M&M, in fairness. e.g.,:

PDF here.
The structured hospital-wide MM&I conference is an effective way to engage multiple members of the health care team in a discussion of adverse outcomes, while collaboratively focusing on potential systems-based improvements in patient care and safety. Nonjudgmental case discussion helps overcome the individual’s fear of accusation and criticism, which can stifle honest exchange of information and hinder improvement initiatives. Identification of potential system failures by participants, empowerment of workgroups to address specific systems-based problems, and transparent accountability for regular followup can lead to improved patient safety.
 "Nonjudgmental case discussion." Yeah, great ideal. But, ever heard the phrase "Shame and blame"? Another link as well (there are many).

(Aug 5th, 8:30 pm update)

My state has finally gotten off its inertial duff and launched its Medicaid EP Meaningful Use Attestation Portal. Better Late (by a year) than Last In The Nation (we were close, though). The fun begins at 8 a.m. Be an interesting couple of days (and week and month). I expect to be on the phone most of the next couple of days doing repetitive hand-holding.

FAQs here (pdf).



Part II of our conversation with McIntyre brought forward some of the challenges his practice faced during meaningful use attestation. He also discussed where he thinks the Centers for Medicare and Medicaid can improve upon the relationship between government and physicians...
In an ideal world, how should CMS handle meaningful use?
I understand they’re trying to standardize the data collection but they should’ve brought a lot more clinicians into the fold in designing this. They had a comment period and relaxed the meaningful use criteria a bit, but I don’t think they really listened. I think they should’ve made Stage 1 a whole lot easier to comply with just to get people involved. Then you can make it more onerous as it goes forward. You already have people on board and you can work the bugs out that way instead of saying ‘Here’s this onerous criteria and you have to do it or you don’t make the money back and oh, by the way if you don’t do it by 2015 we’re going to start to ding you.’

They should’ve brought more doctors into the conversation and sought out expertise from all specialties. With the quality metrics, they should’ve had a broader base of CMQs. I think it’s great that we’re going to follow outcomes, but let’s follow outcomes then. I mostly have a shoulder practice and there’s not one question. There should be outcomes metrics, we have validated outcome metrics – the America Shoulder Elbow score, several other validated scores you could stick into a metrics process that would be great for collecting data. And we need that data, but there’s none of that in there. It’s a top-down, one-size fits all operation. That means it’s going to be hard to implement and it’s not going to be germane to the practice types. The whole idea about collecting data is collecting good data, right?

How do other physicians that you know feel about meaningful use?
I go to a lot of meetings with other orthopedists and there are a lot of hands raised when asked if they’re applying for meaningful use. It’s not like people aren’t doing it.

Doctors are scared to death of this. They’re looking at the cost, number one. Then they’re looking at implementation of it, number two. Then they’re looking at meaningful use criteria number three. All are separate issues. A lot of them are just saying ‘Uncle’. That’s a big reason why so many [practices] are becoming hospital employees. If they paid us more to do this, if we were somehow incentivized, you could justify it but your reimbursements are going down, costs are going up and now you have to comply with these onerous regulations? In my testimony, I said that we’ve reached a tipping point. Doctors just can’t do what they’re being asked to do with the resources they’re being given. The result of that is the rush to consolidation. It’s not like the consolidation wasn’t going on prior to this, but it has hastened it.
Interesting. "If they paid us more to do this, if we were somehow incentivized..."

I have a lot of my own issues with the Meaningful Use initiative, but are we to believe that the $6.1 billion incentive funds thus far disbursed are inadequate? Not to mention the market value of the federally subsidized REC resources engaged by providers?

BTW, the latest update on Meaningful use attestations by vendor product.


Healthcare Communities Portal

" (HC) is a web-based knowledge management system that provides multiple means for the healthcare quality improvement community to share knowledge and contribute to each others’ QI work."

I was just assigned to become a Nevada HEN CoP site administrator (for our Hospital Engagement Network conrtact). Pretty nice. I'm not sure it gets a whole lot of traffic. Interesting stuff nonetheless. I started a Forum post on "workflow." We'll see if it gets any bites.


"We have SNOMED, HL7, ASTM and the like, but little about how to design, build, and test systems. In other words, there is no handbook of clinical software engineering."
What's the real point of meaningful use?
August 06, 2012 | Jeff Rowe, Editor, EHRWatch

So here’s the question: Given the apparent difficulty – in terms of expense and the level of necessary collaboration – in achieving, say, the level of interoperability desired for MU Stage 3, what’s the point of the timeline? Perhaps more importantly, what’s the point of what lies beyond the MU timeline, which are the penalties for those Medicare providers who haven’t yet made the digital leap?

OK, that’s more than one question, but you see where we’re going. The HITECH incentive program is nicely structured to have three levels of implementation goals followed by a period of penalties for those who haven’t figured out how, or decided not, to achieve those goals. But it seems starkly clear that the complicated reality of health IT development and implementation renders that structure seriously unrealistic.


Gotta love it. Thanks for letting me know. This year.

More to come...

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