Sunday, June 26, 2005

IT as a Management Tool

A recent issue of the hospital journal H&HN (Hospitals and Health Networks) included a supplement titled The Future of the EHR (EHR standing for Electronic Health Record). The general theme had to do with the current status of the ongoing effort to create a national health record that would facilitate the movement of patient information among providers, payers, etc.

Among other things, the report unwittingly provided a strong clue to the puzzle of why the health care field finds it so difficult to make productive use of information technology (IT).

In the report, Gary Mecklenberg, CEO of Northwestern Memorial Health Care in Chicago, was quoted as saying “I’m not worried about sending information to California. I want to get it across the street.” It seems that his hospital cannot electronically get test results from a laboratory across the street because different vendors’ information systems are unable to communicate.

Which raises the question of who is accountable for that.

What Gary’s comment reveals is that in the prevailing culture of health care, senior managers are not expected to feel any sense of “ownership” of the IT applications within the institutions for which they are responsible. They may strategize at some conceptual level and they may referee among the various power centers competing for information technology resources. But when it comes to hands-on management of the planning of new applications and making sure that they actually work when implemented, they treat it as something for which they can only depend on the experts.

IT, like accounting, is a management tool that, when properly utilized, permits improvements and efficiencies not otherwise achievable.

Not all senior managers are accountants, but in recent times they have come to be held accountable for the validity of their organization’s financial reporting. When health care managers are held similarly accountable for the effective utilization of IT by the institutions for which they are responsible, their industry will begin to catch up with everybody else.

Saturday, June 25, 2005

Hats Off to the Anesthesiologists

Thanks to John Kelly who calls my attention to the anesthesia and safety story that appeared in the June 21, 2005 issue of the Wall Street Journal under the by-line of Joseph T. Hallinan.

Many of you will have seen the article, which recounts how the American Society of Anesthesiologist reacted to the malpractice insurance problem by improving safety rather than by lobbying for legal means of reducing claims. Over the past two decades, patient deaths due to anesthesia have declined to one death per 200,000 to 300,000 cases from one for every 5,000 cases. Anesthesiologists now typically pay some of the smallest malpractice premiums around, a huge change from when they were considered among the riskiest doctors to insure.

The general story has appeared in other publications, as well.

In transmitting the article, John’s comment was “In all the hand wringing about leadership for improved quality and safety, the story of the field of anesthesiology stands as a consistent reminder that doing the right thing actually does pay long term dividends.”

I would add that it shows the value of responsible professionalism, of which we see too little. Although some of what the ASA did could also have been done by any large hospital that was paying attention to patient safety, other parts of it benefited greatly by the ability of the ASA to collect and analyze large amounts of data collected nationally.

The full article is a worth-while read and can be found at:


Friday, June 24, 2005

Correlation and Causation

It was either a Professor of Statistics or a Professor of Logic who taught me that if a correlation is established between A and B, there are three possible explanations, none of which, on the face of it, can be said to be more likely than another. They are:

A is causing B,
B is causing A, or
A third factor C is causing both A and B.

The June 13, 2005 issue of Modern Healthcare reported a study showing that hospitals in financial difficulty make more medical errors.

Based on these findings, the researchers (two economists with the U.S. Agency for Healthcare Research and Quality) expressed concern that “cost-cutting initiatives might erode patient safety and the safety culture within hospitals.”

In other words, if A is financial difficulty and B is medical errors, they jumped to the conclusion that A is causing B. As might be expected, Richard Wade, speaking for the American Hospital Association, readily agreed. After all, AHA’s main job as a trade association is to get more money for its members.

But what if B is causing A; i.e., making lots of medical errors causes financial difficulty?

Or what if some C is causing both A and B?

If C is management, my inclination would be to opt for the third alternative; i.e., that financial difficulty and medical errors are both being caused by inadequate management.

If I am right, providing more money won’t help. The remedy is to improve the management.

Wednesday, June 08, 2005

HMO’S and Managing Care

Yesterday’s posting was about my brother-in-law Jim who diagnosed his own case of Polymyalgia Rheumatica.

There are some other parts of his experience that seem worthy of note.

Jim’s initial pain was concentrated in his right shoulder and hand. The orthopedist ordered an MRI of the shoulder. Before it was taken, however, the left shoulder and hand started to hurt. This convinced Jim that the right shoulder was not the source of the problem and so he tried to cancel the MRI. However, the orthopedist was on holiday and nobody would countermand the requisition.

At one point late in the process, Jim fainted (probably from pain). By this time his orthopedist had returned from vacation. When Jim saw him the next day, he decided Jim’s condition was somehow “systemic” and referred him back to Internal Medicine for evaluation. Jim’s regular Primary Care Physician (PCP) was not available, so he saw another internist who said she thought she knew what he had but wouldn’t tell and made the referral to Rheumatology (giving Jim the clue that led him to the diagnosis).

Jim’s HMO is only now making physicians available by e-mail. His PCP had it but the specialists didn’t yet. On the visit at which Jim presented his own diagnosis, the PCP said he had not realized how much pain he was in and how quickly the symptoms had multiplied, thereby revealing that he (the PCP) had neither read Jim’s recent e-mails nor (apparently) communicated with the other two docs who had seen him four days earlier.

HMO’s are said to be engaged in something called managed care. Jim’s HMO is well known and prestigious, but when it comes to managing care, it has a ways to go.

Tuesday, June 07, 2005

IT and Imagination

The snail’s pace as which Information Technology (IT) is being implemented in health care can be traced in large part to a lack of imagination.

My brother-in-law Jim recently contracted a case of Polymyalgia Rheumatica, which is medicalese for pain in the muscles. The etiology is unknown. It eventually goes away by itself and until it does the pain can be controlled with cortisone.

Although by no means rare, the disease is uncommon enough, and the symptoms general enough (e.g., “my shoulder hurts”) to make the diagnosis less than obvious.

Jim’s HMO Primary Care Physician (PCP) referred him first to a neurologist who referred him to an orthopedist. Neither resulted in a diagnosis.

The next referral was to a rheumatologist. Although Jim is more than usually facile at Internet searches, his efforts to diagnose himself via Internet had up to then been unsuccessful. But when he heard the word Rheumatology he narrowed his search and bingo!!, hit it right off.

So back to the PCP he went, diagnosis in hand together with the treatment. The PCP accepted the diagnosis and provided the needed prescription.

As one can imagine, Jim was more than a little apprehensive before this last visit about how the PCP would react to being handed the diagnosis and recommended treatment by the patient. Happily, things went well and the condition was in short order brought under control

That shouldn’t have been enough. The HMO should have given Jim a certificate of appreciation and put his picture in its monthly subscriber newsletter. Think of what an HMO could save if more patients were able to diagnose themselves!

The airlines now have us making our own reservations and charge us extra if we need help. Will the day come when patients will have to pay a special fee if they need a doctor’s help in reaching a diagnosis?

In the meantime, should the HMO provide a skilled Internet searcher to help patients reach a diagnosis before seeing the doctor?

Don’t laugh. This is the kind of thing that IT makes possible and the sort of thinking that ought to be going on in the leadership circles of health care.

Wednesday, June 01, 2005

Cost and Prevention

It is not uncommon to hear public figures talks about prevention as a means of reducing health care costs. Some readers will have seen Larry Mathis’ Letter to the Editor on that subject as recently published in Modern Healthcare. The unedited version is below. Larry is the retired CEO of Methodist Health Care System in Houston and a former Chairman of the American Hospital Association.

I have just returned to my home following the American Hospital Association’s annual Washington meeting, where I listened in amazement to our lawmakers and regulators speak about health care costs. One talked about how preventive care and innovative treatments would lower costs; another opined that the new Medicare prescription drug program would lead to lower medical care costs because the drugs would prevent more serious, more costly illnesses.

Are our national leaders hopelessly naïve or, incredibly, do they believe what they are saying?

Health care costs in this country will continue to rise and preventive care and better treatments will be major causes of that rise.

I am a prime example. When I was 44 years old, I suffered a heart attack. I was given tpA, a then experimental clot dissolver, and angioplasty. The treatment worked and, after a two-night hospital stay, I returned to work two days later. This successful treatment was much more effective and less costly than earlier alternatives: serious heart damage, long hospital stays, and a slow recovery and return to work. New technology saved me. It saved me to live on through four subsequent catheterizations, three angioplasties, two stents, and numerous other less serious medical and surgical treatments for a variety of ailments. I’m 61 now, in pretty good health, and I’m looking forward to other successful medical treatments to keep me alive and to lower my golf handicap.

Had I died at age 44 from my first heart attack, I would have spared the health care system the enormous expense of all my subsequent treatments.

The medical establishment cured the infectious diseases that took the young lives of so many: yellow fever, typhoid, typhus, small pox, diphtheria, whooping cough, and etcetera. Those who would have died from those diseases were spared to live on into middle age to develop heart disease. Our physicians and hospitals have made remarkable, but costly, strides in combating that killer, sparing many to live on to develop cancer. Now many cancers can be effectively, but expensively, treated or cured, thus sparing many to live on to develop Alzheimer’s disease at great continuing expense to our health care system.

From a macro-economic perspective, it is cheaper for the system when the patient dies of typhoid at age 19 than to live to be expensively (and successfully) treated for heart disease, cancer, stroke, and Alzheimer’s. Our very success is the enemy of cost reduction.

All of the buzzwords – prevention, early detection, screening, chronic case management – are nothing more than prescriptions for increasing the overall cost of health care in this country. If they save lives, it will cost more.

Based upon what I heard in Washington this week, our lawmakers and regulators seem to believe there is some magic bullet for controlling long-term health care costs. There isn’t. Unless, of course, our government has found a way to insure that we live pristine lives, devoid of smoking, violence, drinking, and risky sexual behaviors, and can provide a magic elixir that will prevent chronic diseases like heart disease, cancer, Alzheimer’s, and stroke and allow us to die peacefully and cheaply at home in our own beds at age 100.

As long as our population grows, as long as our population ages, as long as our hospitals and doctors find new ways to prevent and treat disease and injury, as long as we prize medical innovation and treatment, and as long as someone other than the patient pays for the bulk of it, health care costs will continue their inexorable rise.

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