Wednesday, September 28, 2005

So Much for the Teaching Hospital Mystique

Most of us have been brought up to believe that the best medical care was provided in teaching hospitals. Even US News and World Report and others who undertook to identify the “best US hospitals” believed it and gave credit for membership in the national Council of Teaching Hospitals and for having large residency programs.

Having spent my entire career in teaching hospitals, I was always a little skeptical about all that. I knew that the most advanced medical procedures and treatments usually appeared first in teaching hospitals (where the research that led to them was done) but was not so sure that the more routine cases that occupied most of the beds were always getting such good care. When measuring outcomes started, I predicted that there would be some surprises.

Well, perhaps I was right. The September 22, 2005 issue of the Boston Globe reported that the UMass Memorial Medical Center in Worcester – teaching hospital for the University of Massachusetts Medical School - had closed down its open heart surgery program because of a mortality rate that was twice the average of Massachusetts hospitals. The absolute numbers were 38 deaths out of 917 operations. Reportedly, the Medical Center had been aware of the problem for at least two years, but decided to shut the program down only after being presented with an analysis of the numbers by the Massachusetts Department of Health.

Asked about the delay, Paul Dryer, director of the Department’s Division of Health Care Quality pointed out that it takes time for a state agency to develop such data and suggested that hospitals ought to be the first to know there is a problem and to take some responsibility for dealing with it. Sounds reasonable to me.

So perhaps the reputation enjoyed by teaching hospitals was partly mystique that the UMass example will help to dispel.

Tuesday, September 27, 2005

Another Experience with Animal Medicine

Daughter Eleanor, whose earlier experience with Animal Medicine was the subject of a recent posting, now reports another and concludes with a comment on who should make clinical decisions.

In a truly remarkable set of coincidences I have had further opportunity to notice the difference between human and veterinary medicine.

One of my friends got diagnosed with breast cancer last spring - underwent a lumpectomy and radiation, and found (on her own) a lump in the other breast four weeks ago. After waiting two weeks to get in for the biopsy, she is now going on week four waiting for the results. Call after call to the Doctor’s office has resulted in promises to call back - but so far, no call. Her pushy friends are going to go to the Doc's office with her tomorrow and demand her file (which is her property) and look at the test result.

By contrast, my cat – earlier diagnosed with cancer - had some strange new symptoms on Wednesday. We saw the internist who is filling in for his honeymooning oncologist (that seems like a pretty good excuse to be away to me) on Friday afternoon (I couldn't make it up there in time on Thursday). She examined him in the truck (he freaks out in hospitals) and then spotted the staff neurologist out with some patients. We walked over for a quick consult, which lasted for twenty minutes. Then we went back and did some more checking on Auggie (my cat, named for St. Augustine), after which she went back to her office, looked two things up and came back with another round of chemo therapy in case that was the cause. Two exams, a neuro consult and chemo all in under two hours, and I never left the truck. I forgot to pay the bill before I left - but I will get it in the mail today. I'll be surprised if it is over $200.

Oh, and Auggie's doc called on Saturday to see how he was doing.

Try getting that kind of service in a people hospital.

I then called my ex-husband, a neurobiologist by training - and asked what he thought, did the two tests he suggested and called back the doc - who was happy to get the additional thinking on the problem and I am now waiting for a call back from her after she talks to the oncology and neurology staff again. She'll call tonight (after rounds) or tomorrow AM.

Try to find a people doc who will listen to a Ph.D. non- MD and take it seriously. Or even approach a complex set of symptoms as a systemic problem to be solved. They are out there - but few and far between in my experience.

Harvard Alumni Magazine last month ran an article on the effects of sleep deprivation. I for one will never go to a teaching hospital and be looked at by residents ever again. The data is clear - sleep deprivation makes you stupid, clumsy and irritable. Chronic sleep deprivation may make it irreversible. Maybe this is one of the roots of our problems in human medicine - we don't pay attention to the data.

Who should make medical decisions? I vote for smart, knowledgeable people who have gotten enough sleep.

Wednesday, September 21, 2005

On Visionary Leaders and Computers

Today I sent the following letter to Health Affairs, a prominent academic journal in the field of health care organization and policy, with a copy to the author.

The title of the lead article in the September/October 2005 issue of Health Affairs by Hillestad and colleagues is put in the form of a question; i.e., “Can Electronic Medical Records Transform Health Care?”

The answer to that question is quite clearly no. A bunch of computer entries hasn’t the power to transform anything.

However, able and dedicated people, led by competent and knowledgeable visionaries, who undertake to transform care in well structured, tightly disciplined health care organizations, will find information technology to be a tool with vast potential.

What we need is not so much a quantification of the possibilities of information technology as a better understanding of (a) why our health care delivery system is frozen in the past, seemingly unable to imagine and implement new and better methods of delivering health care using 21st century capabilities, and (b) what might be done about it.

We’ll see if anybody pays attention.

Friday, September 16, 2005

More on the Mayo Clinic, Council Bluffs Police, and IT

Herewith comments from consultant and fellow U of C alum John Kelly:

Okay Richard, I have to admit that the note on the Council Bluffs Police Department vs Mayo Clinic online appointments is both accurate and witty. However, as I’m sure you know, this is not limited to just Mayo. Most of the ‘big boys’ in the medical world are leagues behind the rest of the country in basic notions of customer service and using the power of the computer.

Now, having taken my parents to Mayo on several occasions for the visits to the doctor I am amazed at how backward Mayo is with simple customer conveniences. Note please that my father was a practicing Mayo physician for over 40 years and now find himself in the unenviable position of being a patient…he is aghast at the service (or lack thereof).

One simple reason explains this (in my humble opinion) – simple arrogance.

Wednesday, September 14, 2005

Health Care Still Doesnt Get IT

Healthcare Executive. a publication of the American College of Healthcare Executives, is directed, as its title implies, to executives in the field of health care. Its September/October 2005 issue features two articles on the subject of Information Technology (IT) as it relates to health care.

A full and careful reading of both articles reveals with unusual and, most likely, unintended clarity the conceptual fog that blankets the general subject of applying IT in the provision of health care.

Put in the simplest terms, IT is a management tool – a very powerful tool, to be sure – but a tool nonetheless. As such, it allows management to improve operations in ways that would otherwise be impractical – even impossible.

But if the potential of IT is to be realized, management must be clear about the operations it wants to improve, how it wants to improve them, and how it will use IT to do so.

That is where the application of IT in health care has foundered. The goals served by IT in the instances described in the Healthcare Executive articles range from physician order entry through vague quality improvement initiatives to creating a statewide patient identifier. The practical benefits, after discounting for the usual CEO hyperbole, have been unimpressive, to put it mildly. One of the articles states that “So far, many hospitals and health systems have not realized significant, or even positive, returns on their IT investments.” In other words, much of the money spent has been wasted.

Actually, one gets the distinct impression that the various IT projects mentioned were motivated not so much to improve operations as by the desire of healthcare executives to look progressive in the face of the growing chorus of criticism they face for being so slow to make productive use of IT.

The truth is that successful healthcare managers have never been operationally oriented. Instead they have focused on managing relationships with and among the guild-like power centers within their organizations, on managing finances, and on the growth and development of the institutions for which they are responsible. Tinkering in operations risks impinging on the carefully protected turf of one powerful guild or another and has, therefore, been avoided.

So what we tend to see in health care are flurries of IT activity that too often involve buying some popular application, or one being touted by an influential power center, in the hope that something good will come out of it in addition to bragging opportunities and short-term peace. The dismal long-term results are predictable.

One might put it this way – health care still doesn’t get IT.

Monday, September 12, 2005

Cause for Alarm

Walking past the newspaper bins of the local supermarket last Saturday my eye was caught by the following headline on the front page of the Sunday edition of The Patriot Ledger (a regional newspaper serving the Boston area South Shore):

“Hospitals seek Rx for human error.”

The lead sentence was: “An elderly man died after receiving 60 times the recommended dose of a sedative at Brockton Hospital, a state investigation report says.” The town of Brockton is located some 40 miles or so south of Boston. The story also reported two medication errors that occurred in the South Shore Hospital located in South Weymouth.

A sidebar to the story reported citations for record keeping violations issued by the Massachusetts Department of Health to Jordan Hospital, located in Plymouth. The violations dealt with the use of patient restraints without properly documented physician orders.

Both stories appeared under the byline of a local reporter and were played “straight;” i.e., without editorial comment. In the Brockton case, the story reported deadpan fashion that the pharmacist had realized the mistake and telephoned the nurse to correct it, but the nurse wasn’t there and the pharmacist told investigators he “forgot to follow through.”

In the Jordan Hospital case, spokesman John Looney said that the hospital has rewritten its policy to conform to the rules and that the doctors would be informed. He went on to say that the hospital expects nurses to tell doctors if their orders don’t comply with the rules. (Some might think management ought to have some responsibility for enforcing policy.)

Surely confidence-destroying stories like this should be cause for alarm by hospitals. One wonders how bad it has to get before they are.

Thursday, September 08, 2005

If Doctor Doesn’t Know Best, Who Does?

An article in the September 6 issue of the Boston Globe reports that Massachusetts Blue Cross will soon begin to require preapproval for certain expensive imaging procedures, such as MRIs and PET scans.

According to the article, Harvard Pilgrim Health Care has had such a program since last year and Tufts Health Plan will initiate one on October 1. These are the other two major health insurers in Massachusetts.

The real significance of these initiatives seems no more to be recognized now than was the case during the managed care era of the 90’s when they were commonplace.

What these insurance companies are saying is that doctors are ordering expensive tests that are not needed. Or, to put it more bluntly, that doctors are making bad decisions that waste money.

Our entire system of health care is based on the principle that doctor knows best. Patients present themselves to doctors, doctors decide what should be done, and the rest of the system is responsible for doing it and paying for it.

Now it seems that insurance companies no longer accept this basic principle. Instead, they are inserting themselves into the medical decision-making process and refusing to honor decisions that they consider to be wrong.

Which leaves us with a big question: If doctor doesn’t know best, who does?

The answer to that question will go far to determine the design of the health care system of the future.

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