Tuesday, August 04, 2015

The medical arms race made visible

With thanks to Priyanka Dayal McCluskey at the Boston Globe, we can get a glimpse of one "small" part of the medical arms race in action.  The story is about the expansion of Mevion Medical Systems Inc., a manufacturer of proton beam machines.  The company offers the "more affordable price tag of about $25 million" per machine, compared to the first generation $250 million models.

Here's the arms race quote:

Three Mevion systems are treating patients at hospitals in St. Louis, Jacksonville, Fla., and New Brunswick, N.J. Four others are being installed. The company is developing about 20 other orders. 

Here's the relevant context:

“In a perfect world, if the capital costs were the same, proton therapy is something you’d want all patients to receive,” [MGH's Jay] Loeffler said, “but because of the capital costs, it has to be limited in use to only the situations we believe it’s best for.” This includes tumors in children and tumors in adults that are in or near critical body parts like the brain or eyes.
Some hospitals use proton therapy to treat prostate cancer — even when there is no scientific evidence it’s a more effective treatment than traditional radiation, said Dr. Durado Brooks, director of cancer control intervention for the American Cancer Society.
“Because it’s newer doesn’t necessarily mean it’s better’’ for prostate cancer, he said. “At this point we just don’t know.” 
Here's an endorsement about the science behind the machine presented on the company's website:

What is American Shared Hospital Services?

American Shared Hospital Services is a publicly traded healthcare company (New York Stock Exchange AMEX symbol AMS) with a 25-year track record of leasing state-of-the-art medical equipment to hospitals and medical centers in the United States.

Through GK Financing, LLC (GKF), our majority owned subsidiary, we are the leader in Gamma Knife unit ownership with approximately a 16% market share in the United States. Our Gamma Knife model has been expanded to incorporate the financing of other technology solutions including Intensity Modulated Radiation Therapy (IMRT), Image-Guided Radiation Therapy (IGRT) and Proton Beam Radiation Therapy (PBRT).

In the corporate history, we note these items:

2006: We enter the proton beam radiation therapy (PBRT) market by acquiring an equity interest in Still River Systems, Inc., developer of the Monarch 250, a practical, cost-efficient, single room PBRT system. In turn, we are able to contract with Tufts Medical Center in Boston, MA. for a complete radiation therapy department upgrade that includes an IMRT/IGRT as well as a single-room PBRT system. 

We contract with Orlando Regional Healthcare M.D. Anderson Cancer Center in Orlando, FL on our second single-room PBRT facility. 

2007: We increase our equity interest in Still River Systems, Inc.

2008: We agree to provide Todd Cancer Institute at Long Beach Memorial Hospital, in Long Beach, CA with a single-room PBRT facility – our third to date. 

2009: We sign a letter of intent with the Todd Cancer Institute at Long Beach Memorial Hospital, in Long Beach, CA for a single-room PBRT facility – our third to date. 
I know you'll join me in being glad that ASHS has no vested interest in this product and is highly qualified to present a scientific opinion!
Let's recap. "We just don't know" if it's better, but Mevlon has sold or will sell 27 installations at $25 million, or $675 million.  Oh, aided and abetted by a Medicare pricing regime that provides higher rates for use of the machine.  The company notes:
Treatment sites where proton therapy is used:

Pediatric Tumors
Head and Neck
Brain
Eye
Prostate
Lung
Breast
Gastrointestinal
Gynecologic
Genitourinary
Sarcoma
Lymphoma 

Monday, August 03, 2015

The board has to be on board

Those of us who have run hospitals where we've been serious about achieving improvements in quality and safety know that without a highly committed board of trustees, the results will never be sustainable. And so it is lovely to see documention of that premise in a new article by Thomas C. Tsai, Ashish K. Jha, Atul A. Gawande, Robert S. Huckman, Nicholas Bloom, and Raffaella Sadun in Health Affairs. I reprint the abstract:

National policies to improve health care quality have largely focused on clinical provider outcomes and, more recently, payment reform. Yet the association between hospital leadership and quality, although crucial to driving quality improvement, has not been explored in depth. We collected data from surveys of nationally representative groups of hospitals in the United States and England to examine the relationships among hospital boards, management practices of front-line managers, and the quality of care delivered.

First, we found that hospitals with more effective management practices provided higher-quality care. Second, higher-rated hospital boards had superior performance by hospital management staff. Finally, we identified two signatures of high-performing hospital boards and management practice. Hospitals with boards that paid greater attention to clinical quality had management that better monitored quality performance.

Similarly, we found that hospitals with boards that used clinical quality metrics more effectively had higher performance by hospital management staff on target setting and operations. These findings help increase understanding of the dynamics among boards, front-line management, and quality of care and could provide new targets for improving care delivery.

Where would you rather serve?

Which is more hierarchical, the military or health care?

A medical student who had served as a corpsman in the military attended our Telluride Patient Safety session last week.  She noted her experience while on clinical rotations:

I thought that when I got into medical school that I would be in a safe place to learn. . . and it wasn't. 

I couldn't believe that I was now in a system where I couldn't speak up.

As a medical student, I feel like my concerns are disregarded. Coming from the military, where every concern is heard, it's critical.

Sunday, August 02, 2015

On checklists

This article by Emily Anthes about checklists in Nature notes:

Poor use of checklists means that people may be dying unnecessarily. A cadre of researchers is . . . finding a variety of factors that can influence a checklist's success or failure, ranging from the attitudes of staff to the ways that administrators introduce the tool. The research is part of the growing field of implementation science, which examines why some innovations that work wonderfully in experimental trials tend to fall flat in the real world. The results could help to improve the introduction of other evidence-based programmes, in medicine and beyond.

Totally predictable, as Captain Sullenberger noted over four years ago:

A checklist alone is not sufficient. What makes it effective are the attitude, behavior and teamwork that go along with the use of it.

Saturday, August 01, 2015

Silent sovereigns of the forest

In Travels with Charley, John Steinbeck portrays the physical and emotional grandeur of the great West Coast trees:

The redwoods, once seen, leave a mark or create a vision that stays with you always.  No one has ever successfully painted or photographed a redwood tree. The feeling they produce is not transferable. From them comes silence and awe. It's not only their unbelievable stature, nor the color which seems to shift and vary under your eyes, no, they are not like any trees we know, they are ambassadors from another time. They have the mystery of ferns that disappeared a million years ago into the coal of the carboniferous era. They carry their own light and shade. The vainest, most slap-happy and irreverant of man, in the presence of redwoods, goes under a spell of wonder and respect. Respect--that's the word. One feels the need to bow to unquestioned sovereigns.

And it persists even after their death. In a welcome break from hours of discussion about patient harm and clinical process improvement, our Telluride scholars made a visit to the Petrified Forest in Calistoga. There we saw massive trees that had been blown over by the St. Helena volcanic eruption 3.4 million years ago. Two-thousand-year-old trees were felled in an instant, then slowly petrified in the resulting ash.

Branch holes remained where limbs had been torn away by the volcano's force.

Rock-hard age rings, likewise, show the years of growth.

Even in their petrified form, these 300-foot trunks held us in awe. Steinbeck says:

There's a remote and cloistered feeling here. One holds back speech for fear of disturbing something--what? Can it be that we do not love to be reminded that we are very young and callow in a world that was old when we came into it? And could there be a strong resistance to the certainty that a living world will continue its stately way when we no longer inhabit it?

Friday, July 31, 2015

Ain't the way to die

Here's a different take on end-of-life issues from ZDoggMD.  Worth watching and perhaps using in your place to get the conversation started.

(Thanks to Dr. Susan Shaw in Saskatoon for the reference.)

Thursday, July 30, 2015

An individual and organizational moral obligation

My buddy Jeff Thompson is stepping down as CEO of Gundersen Health System in a few months.  I have commented several times here on Jeff's leadership abilities, which are again demonstrated in a note he sent to his staff this week.  In simple, direct terms he reinforces the narrative that is at the heart of his hospital's purpose.  It could be the same purpose of any hospital in the world, but it is not often set forth so well.  An element of leadership is that the narrative is expressed in so eloquent and elegant a fashion--one that permits all recipients to feel ownership of the privilege and obligation they have been given.

Dear Colleagues,

We are experiencing many changes as an organization. Some are very exciting like Dr. Rathgaber taking over as CEO in September. Others are more of a struggle. There is always going to be change, especially in our business.

But it is not the changes that are the most important.  It is how we respond. How we respond to change as individuals, teams and as an organization is what defines us. It will determine our futures and move us from good to great.

Sounds good, but change can be very scary.

Here’s what won't change: Our mission to improve care, lower cost and improve the health of the community. This rises beyond growth targets, financial goals and facilities plans. It really is an individual and organizational moral obligation.

To take on big responsibility and big changes, it is best to start with a great platform as a base. The solid platform we have should give us great confidence going forward.  In the face of higher quality standards, economic down turns, tons of regulation and increasing competition, you as teams and we as an organization have steadily improved on all of our key strategies.

Going forward it boils down to just a couple of really big things: Take care of our patients and take care of each other.  The "patient" part has expanded to "patients, families and communities" and each other needs to include those well beyond our immediate work groups to colleagues and partners.

Although changes will always cause some struggles, we have no reason to fear them. We need to trust our strong platform, our clear path and a great team to not just survive but truly excel through the change.

I know we are up for the challenges.

Sincerely,

Wednesday, July 29, 2015

When CEO bonuses are tied to US News rankings

Here's a quiz.  Can you guess who posted the following messages on Twitter?

Any idea how many hospital execs' bonuses are tied to their institution's U.S. News rankings?

When execs confide this arrangement, they expect me to be impressed or flattered. Are you kidding? I'm deeply disturbed.  

In my view it's a symptom the board has abdicated its responsibility to measure, monitor & incentivize quality improvement.

You might be surprised to learn that it was Ben Harder, @benharder, chief of health analysis at US News and World Report, the magazine that publishes "data, rankings & tools to help consumers choose hospitals, doctors, health plans & more."

Probably more than anyone in the country, Ben understands the inherent limitations in any such rankings. More important, he understands that the rankings are designed to advise patients with complex medical conditions.  They are not an indication about the general level of quality of care or safety in an institution.

He certainly knows that hospitals use the rankings in their marketing materials, but he understands that what makes marketing effective is different from what makes it possible for a hospital to deliver the highest level of care and to engage in ongoing clinical process improvement.

Bravo to Ben for putting this out there so clearly. I'm hoping board members take note.

Tuesday, July 28, 2015

Student observations from Telluride West

Here are some excerpts from just a few blog posts written by medical and nursing students after the first day the Napa version of the Telluride Patient Safety Camp (seen here having lunch!)  I encourage you to read others:

--

They would act as though nothing is wrong.

I wrote this quote down on my pad during the Lewis Blackman video that was shown today because I’ve been guilty of this during rotations myself. Hellen Haskell, Lewis’ mother, was talking about the nurse taking care of her son and the fact that nursing notes ultimately revealed that she was indeed deeply concerned about the patient and his deteriorating clinical condition.
 
The truth is I don’t quite know how to act (maybe act is the wrong word) or rather what emotions to show around families. No one ever tells you to show a impassive face, to act as if everything is proceeding according to plan even when your team is struggling to figure out what is wrong, yet this is exactly what one learns observing the behavior of residents and attendings.
 
I suppose I always assumed that it was more comforting for families to feel like the providers had a handle on the situation. However, having heard from the patient and patient family perspective, I recognize how isolating and invalidated it can be to feel as if you are the only one concerned about your loved one’s care. While there is a time, a place, and an extent to which to share one’s emotions with patients and their families, honest communication throughout a patient’s stay can create a foundation of trust that can be critical in the terrible event an adverse outcome occurs.  (Neelaysh Vukkadala)
 
--
 
We started the day with the Lewis Blackman story. It was a very sobering, raw look at what healthcare should not be. Everything that could go wrong did in this case. No one could see the forest for the trees. I felt sad as a provider, devastated as a parent and could not imagine the strength that Helen has to go on and share this with others.

The whole story reminded me of my mother in law (who had cancer). She had epigastric pain & went to the ER. She was told she was constipated from her pain meds-and they missed her massive MI. Mom walked into the ER but never walked out. She lived the rest of her days (2 months) in a nursing home since she could no longer care for herself due to the injury from the missed MI.  She ultimately died from heart failure shortly after her MI-not the cancer she had been battling. We thought she would be with us for about another year-but we got that time stolen from us. In our case, my husband and I talked and decided not to pursue legal action since we knew she likely did not have much time left. He approached someone who he was friends with in hospital administration and let him know about the missed MI. He told him that he didn’t plan to pursue any legal action but did want to talk about how this could be avoided in the future. The guy he thought was his friend suddenly did not take his calls anymore. How sad. There are far too many stories like this.  (Tanya Celia)

--

Throughout the day, I couldn’t help but keep thinking about the importance of communication between the healthcare team and the patients that they serve. If there is no transparency, patients and their loved ones (even those well-versed with the medical system) feel like they are left in the dark — during the most stressful time of their lives, they have the added burden of trying to figure out what it is their doctors, nurses, and auxiliary team are actually doing. Lewis Blackman’s story is powerful in that it illustrates the importance of honesty. Watching the video left me with so many ‘if; statements. If the resident or intern working with the nurses had taken pause to discuss Lewis’s worsening condition, could this all have been avoided? What if the doctors and nurses had been more upfront about their lack of understanding of Lewis’s situation? What if Helen had been able to directly contact the attending, would he/she have listened to her pleas and ordered tests to reveal the ulcer? What if there had been a system implemented in the EMR to alert attendings when vital signs were out of whack? As an engineer by training, I believe we should create a framework so that even when humans make mistakes, the system in which we operate is able to provide a safety net to catch that one mistake that could mean life or death.  (Sunny Kung)

---

As students of medicine, we are constantly learning: from understanding how to create a robust differential diagnosis, to figuring out ways to chart a patient’s progress through an electronic health record. We drink thousands of new words from a firehose every day, hoping to eventually master the mesmerizing and powerful medical language. With this constant influx of new information, it is easy to forget perhaps the most important facet of our patients’ care: a meaningful relationship founded upon trust. Regardless of the hours spent memorizing biochemistry textbooks, if we as health care professionals cannot find a way to communicate with our patients, we will fail to provide our patients with high quality care. (Serena Dasani)

--

The general feeling I left the end of Monday with was discomfort. The idea that I will be taking the reins on patient care in three short years is a terrifying thought. I hope that I can draw on lessons from Telluride to remember to stay goal oriented, patient centered, and most of all scared in order to provide safe, quality care. (Alexandra Butz)

--

The corridor faded as her trust weakened
Ending a life, hopes, and dreams
Learning to cope with how we failed her
Leaving her impressions fluid in the rigid system
Unavailable.
Rising and challenging us to remember the center
Instill our pledge in our actions
Demanding change to our discussions
Establishing humanity in our calling  (Natalie Elder)

Yes, even surgeons can learn

The Risk Management Foundation of CRICO recently supported a research program to test the effectiveness of 360 degree reviews in influencing surgeons' communication and behavioral skills.  The results were just published in the Journal of the American College of Surgeons.

The context was important:

The program was deployed as part of a long-standing, surgical chief-led patient safety and quality collaborative. The collaborative had previously constructed a Code of Excellence (COE), an explicit description of behaviors expected of all surgeons within their departments. The 360 degree evaluation process was designed to assess progress towards these standards.

Here's how the study was designed:

Three hundred and eighty five surgeons in a variety of specialties [in the Harvard hospitals] underwent 360-degree evaluations with a median of 29 reviewers each. Beginning six months after evaluation, surgeons, department heads, and reviewers completed follow-up surveys evaluating accuracy of feedback, willingness to participate in repeat evaluations, and behavior change.

Here are the results:

Survey response rate was 31% for surgeons, 59% for department heads and 36% for reviewers. Eighty seven percent of surgeons agreed that reviewers provided accurate feedback. Similarly, 80% of department heads felt the feedback accurately reflected performance of surgeons within their department. Sixty percent of surgeon respondents reported making changes to their practice based on feedback received. Seventy percent of reviewers elt the evaluation process was valuable with 82% willing to participate in future 360 degree reviews. Thirty two percfent of reviewers reported perceiving behavior change in surgeons.

And the conclusions:

360-degree evaluations can provide a practical, systematic, and subjectively-accurate assessment of surgeon performance without undue reviewer burden. The process was found to result in beneficial behavior change according to surgeons and their co-workers.

Monday, July 27, 2015

"This is bad for academic medicine"

When the history of the patient safety movement is told, it will be appropriate that the Association of American Medical Colleges* will be left out.  The recalcitrance of this organization in acknowledging patient safety problems was legendary for the first decade of this century. The AAMC's leadership not only refused to acknowledge the depth of patient harm but also precluded use of the organization's arms in working on the issue.

For example, when an AAMC committee was to be established in the mid-2000's on patient quality and safety issues, the leadership insisted that the word "safety" be omitted from the committee's name and charter.

For example, when people would submit articles on patient safety to the AAMC's main journal, Academic Medicine, they would be summarily refused, refused even the courtesy of peer review.  The authors were told that patient safety was not an issue of public concern and therefore did not warrant space in the journal.

For example, at sessions with the world's experts on patient safety and doctor education (like Don Berwick and Lucian Leape), high officials from AAMC would reiterate their belief that hospitals did not have a patient safety problem.

Things finally changed in 2010, when a new CEO arrived.  In an article, he and the organization's president addressed the issue:

In order to develop a health care culture of safety that leads to clinical improvements, an unprecedented collaboration between medical schools and their partnering health systems is required, according to Drs. Kirch and Boysen. They identify five factors critical to the success of a culture shift: leadership from the top, student involvement, a focus on safety during residency training, health information technology, and teamwork among health professionals. “When combined with a growing investment in comparative effectiveness research, these factors will help physicians improve care at the bedside,” the authors write.

I suppose better late than never, but think about the societal loss caused by the absence of the major academic medical organization from this issue for so long--notwithstanding important findings by the Institutes of Medicine on the topic.

Perhaps the AAMC leadership reflected the views of its membership.  I recall, when I was emphasizing patient harm on this blog and posting clinical outcome data, the Chair of the Partners Healthcare System called the Chair of our system and said, "Can you get Paul to stop publishing those numbers.  This is bad for academic medicine."

Or perhaps the membership took direction from the AAMC leadership, who, after all, were highly regarded in the profession.  Either way, the lack of action on and attention to patient safety was a significant failure and led to the slow inclusion of patient safety curricula in America's medical schools. Let's consider, therefore, that the AAMC contributed for years to the delay in addressing the large number of preventable deaths and harm in America's hospitals.

--

* As noted in its materials: The Association of American Medical Colleges is a not-for-profit association representing all 144 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems, including 51 Department of Veterans Affairs medical centers; and nearly 90 academic and scientific societies. Through these institutions and organizations, the AAMC represents 148,000 faculty members, 83,000 medical students, and 115,000 resident physicians.

Telluride goes to Napa

A hearty welcome to the newest participants in the Telluride Patient Safety Summer Camps, taking place this week in Napa, CA.  Here's a sample of the medical students and nursing students who are attending:
















Sunday, July 26, 2015

Man has to have feelings and then words before he can come close to thought

Back in 1962, John Steinbeck published Travels with Charley, a series of stories and observations from interactions with people across America.  I happened to pick it up yesterday to re-read it, about 50 years after the first time it was assigned to me in junior high school.  Early in the book Steinbeck relates a discussion he has with a New Hampshire farmer about what was still a major post-World War II concern, the recent development and spread of nuclear power and weapons.

The farmer says,

"Take my grandfather and his father.  They knew some things they were sure about. They were pretty sure give a little line and then what might happen.  But now--what might happen?"

"I don't know," responds the author.

"Nobody knows. What good's an opinion if you don't know. My grandfather knew the number of whiskers in the Almighty's beard. I don't even know what happened yesterday, let alone tomorrow. He knew what it was that makes a rock or a table. I don't even understand the formula that says nobody knows. We've got nothing to go on--got no way to think about things."

The farmer leaves and Steinbeck reports (my emphasis):

"I found I couldn't read, and when the light was off I couldn't sleep.  The clattering stream on the rocks was a good reposeful sound, but the conversation of the farmer stayed with me--a thoughtful articulate man he was. I couldn't hope to find many like him. And maybe he had put his finger on it. Humans had perhaps a million years to get used to fire as a thing and as an idea. Between the time a man got his fingers burned on a lightning-struck tree until another man carried some inside a cave and found it kept him warm, maybe a hundred thousand years, and from there to the blast furnaces of Detroit--how long?

"And now a force was in hand how much more strong, and we hadn't had time to develop the means to think, but man has to have feelings and then words before he can come close to thought and, in the past at least, that has taken a long time."

Now, look at this article about genetic engineering from Wired.  Excerpts:

140 scientists gathered here in 1975 for an unprecedented conference. They were worried about what people called “recombinant DNA,” the manipulation of the source code of life. It had been just 22 years since James Watson, Francis Crick, and Rosalind Franklin described what DNA was.

Preeminent genetic researchers like David Baltimore, then at MIT, went to Asilomar to grapple with the implications of being able to decrypt and reorder genes. It was a God-like power—to plug genes from one living thing into another. Used wisely, it had the potential to save millions of lives. But the scientists also knew their creations might slip out of their control. They wanted to consider what ought to be off-limits.

At the end of the meeting, Baltimore and four other molecular biologists stayed up all night writing a consensus statement. They laid out ways to isolate potentially dangerous experiments and determined that cloning or otherwise messing with dangerous pathogens should be off-limits. A few attendees fretted about the idea of modifications of the human “germ line”—changes that would be passed on from one generation to the next—but most thought that was so far off as to be unrealistic. Engineering microbes was hard enough. The rules the Asilomar scientists hoped biology would follow didn't look much further ahead than ideas and proposals already on their desks.

But then:

Earlier this year, Baltimore joined 17 other researchers for another California conference. The stakes, however, have changed. Everyone at the Napa meeting had access to a gene-editing technique called Crispr-Cas9, [which] makes it easy, cheap, and fast to move genes around—any genes, in any living thing, from bacteria to people. “These are monumental moments in the history of biomedical research,” Baltimore says. “They don't happen every day.”

Using the three-year-old technique, researchers have already reversed mutations that cause blindness, stopped cancer cells from multiplying, and made cells impervious to the virus that causes AIDS. Agronomists have rendered wheat invulnerable to killer fungi like powdery mildew, hinting at engineered staple crops that can feed a population of 9 billion on an ever-warmer planet. 

Bioengineers have used Crispr to alter the DNA of yeast so that it consumes plant matter and excretes ethanol, promising an end to reliance on petrochemicals. Startups devoted to Crispr have launched. International pharmaceutical and agricultural companies have spun up Crispr R&D. Two of the most powerful universities in the US are engaged in a vicious war over the basic patent. Depending on what kind of person you are, Crispr makes you see a gleaming world of the future, a Nobel medallion, or dollar signs. 

The technique is revolutionary, and like all revolutions, it's perilous. Crispr goes well beyond anything the Asilomar conference discussed. It brings with it all-new rules for the practice of research in the life sciences. But no one knows what the rules are—or who will be the first to break them.

Now, think back to Steinbeck:

"And now a force was in hand how much more strong, and we hadn't had time to develop the means to think, but man has to have feelings and then words before he can come close to thought and, in the past at least, that has taken a long time."

In the past, it was the military-industrial complex, now it's the medical-industrial complex. Driven by ego of people who are too sure of themselves and the greed of those seeking to park their cash, the likelihood of effective and thoughtful controls is likely to proceed at too slow a rate to protect us from ourselves. Now here's an issue worthy of attention by the multitude of presidential candidates: Will any step up to address it?

Saturday, July 25, 2015

Everyone likes to think they are doing better

Tissue plasminogen activator
I recall a wonderful story from Amitai Ziv, the director of MSR, the Israel Center for Medical Simulation at Sheba Medical Center on the outskirts of Tel Aviv.  He relates how Israeli fighter pilots would return from their missions and debrief how things went.  The self-reported reviews of performance were very good.  Then, the air force installed recording devices on the planes, and it turns out that the actual performance was not nearly as good as had previously been reported.  The conclusion: It's not that people are poorly intentioned or attempt to mislead about their performance. It's just that we tend to think we are doing better than we actually are.

Let's turn to health care.  Here's a recent story by Lisa Rapaport at Reuters that portrays a problem and--as in the Israeli example above--demonstrates the importance of transparency--providing staff in a hospital with actual data about their clinical performance. The lede:

Many hospitals overestimate how quickly they give stroke patients a clot-busting treatment designed to help minimize damage, a U.S. study suggests.

Researchers asked hospital staff how fast they administered an intravenous (IV) therapy known as thrombolysis to dissolve clots and compared the answers to stroke registry data with the actual times.

Only 29 percent of hospitals had an accurate sense of their own speed.

“Everyone likes to think that they are doing better,” senior study author Dr. Bimal Shah, a researcher at Duke University School of Medicine.

The slowest hospitals were also the ones most likely to be inaccurate about their results.

The gap between perception and reality was far bigger for hospitals that were generally slower.

Among the lowest-performing hospitals, staff surveyed generally thought that at least 20 percent of treated patients got the therapy within an hour. In reality, none did.

Despite their lack of speed, 85 percent of the low-performing hospitals reported their performance as average or above, with almost 5 percent of them ranking themselves as superior in comparison with other hospitals nationwide.

Those of us who are Lean adherents believe in the idea of visual cues, providing data about an organization's performance in real time to those working in an area.  That information helps a place monitor its performance and look for ways to improve and sustain improvement.

It looks like stroke centers and their patients could benefit from such real-time reporting.  As Dr. Shah notes, “Not acting quickly makes the prognosis for stroke patients worse.”

Friday, July 24, 2015

Cups half full and half empty

I've been enjoying an exchange over at Twitter with Ben Harder, @benharder, chief of health analysis at US News and World Report.  As he notes, "We publish data, rankings & tools to help consumers choose hospitals, doctors, health plans & more."

In previous posts, I've expressed major reservations about the methodology used by the magazine.  Regular readers might recall my 2011 column where I said:

US News needs to stop relying on unsupported and unsupportable reputation, often influenced by anecdote, personal relationships and self-serving public appearances.

To his credit, Ben has been working on creating a more objective basis for his magazine's rankings, but there is a still a major component that relies on doctors' opinions.  I wish him well in continuing to make this whole exercise more scientific. (By the way, as the magazine notes, their ranking is not for patients with "normal" levels of acuity, but rather is designed to focus on which hospitals best handle the more complex cases. You'd never know that based on how hospitals use the rankings in their advertisements.)

Meanwhile, it has been revealing to focus on other comments in the Twitterverse and blogosphere that have attacked as unconscionable recent stories from ProPublica in which Medicare data on readmissions were used to describe complications rates for America's surgeons.  Oddly, I cannot recall any of the authors of those diatribes taking on any methodological aspects of the US News rankings.

My guess is that the US News rankings have become such an important part of the marketing campaigns of America's hospitals and doctors that any such problems fall away in the eyes of the profession.

But back to our interchange.  Ben notes, with optimism:

Thru NSQIP & PQRS, @AMCollSurgeons "has begun the long, arduous process of [public] quality assessment" of surgeons.

Surgeons' work on "assessing and improving surgical outcomes...will take some time. It’s complex."

I responded:

NSQIP has existed for years. No indication that it will be used for public reporting. Ever. [Note: More on that here.]

I also noted:

Also c new AUA data effort: "By urologists. For urologists." Public disclosure not contemplated. U c progress. I c recalcitrance.  [Note:  Check here for a description of the American Urological Association Quality Registry inititaive.]

His reply:

You may be right. But the winds of change are blowing. Growing # of surgeons want  #NSQIP to open up.

I offered:

Winds of change? More like gentle whispers. As we say in politics, count the votes. Inertia's winning.

He answered:

You see cup empty. I see rain clouds.

I added:
 
In short, the medical priesthood prevails: "You are not worthy to judge us."

He answered:

Priests will be priests. The congregation is losing its religion.

To which all I can now do is respond by saying, "We shall see."  I see nothing on the horizon that suggests that the public's need to know is as yet offsetting the profession's desire to hold things close to the vest.  When the numbers suit them, the profession extolls the results.  When the numbers don't suit them, it's back to: "The data are wrong.  My patients are sicker."

Thursday, July 23, 2015

Care to discuss Faulkner?


I happened to be looking through an old Doonesbury collection and found this one.

Human factors and EHRs

Perhaps you don't want discouraging news about electronic health records. If that's the case, browse on to another site.  However, the authors of this new paper have some important things to say.  And they have the expertise to be credible, being part of the National Center for Human Factors in Healthcare.

The short version is that EHRs have not been designed with sufficient attention to human factors and therefore are likely to be not as usable as they should be and--I extrapolate--have the potential to cause harm.

First, some background on the topic:

The usability of any device or system can be broken down into two major categories: basic interface design (human factors [HF] 1.0) and cognitive support of the user (HF 2.0). The basic interface design should follow well-established principles that ensure information is clear and readable, such as font size and color, while also providing adequate contrast between text and the background. Focused on the cognitive support of the user, HF 2.0 entails much greater detail and a deep understanding of the workflow and cognitive needs of the user. Designers focusing on HF 2.0 principles seek to understand how users accomplish their work in the context of their actual work environment (e.g., observations, task analysis, and other ethnographic techniques) and engage in iterative user testing of the interface throughout the development process.

Next, an assessment of the "state of the art:"

We are . . . concerned about the lack of progress in addressing HF 2.0 challenges. Nearly all EHR vendors, both large and small, struggle with the challenge of designing for numerous permutations of workflows, clinical specialties, and physical environments in which their EHRs are deployed.( Yet these systems must be designed with the cognitive needs of the frontline users in mind for each specialty and each user role (physician, nurse, tech, clerk, etc.). For example, an HF 1.0 patient discharge tool may have the necessary textbox fields that allow the provider to enter all of the important discharge instructions. But an interface incorporating HF 2.0 design principles would ensure easy access and display of relevant nursing notes, changes in patient status and vital signs, automatically highlight abnormal test results, and suggest follow-up information based on those results. In current systems, abnormal findings and change in a patient's status are easily missed during the discharge process, despite the fact that the information is contained somewhere in the EHR, just not presented in a meaningful way to the user.

Recommendatons:

To do this well, EHR vendors, health care systems, and frontline health care workers need to partner so that all can deeply appreciate the intersection between the technology and the users and design the system accordingly. These efforts must leave adequate time for testing the systems during the development process, and should not be rushed after the system is built and ready to be implemented. 

From our experience in studying EHRs and their implementations, we believe that health care systems and vendors would be well served by a library of lessons learned and use cases that they can draw upon to design and install their systems. Too often, health care systems undertaking a new EHR installation find themselves reinventing the wheel and repeating the same mistakes and missteps that another institution made previously. This is neither sustainable, nor desirable when it comes to implementing safe and efficient health IT systems. 

Wednesday, July 22, 2015

VITAL link at Highmark

Highmark Health has started a new program to introduce innovative products to doctors and patients.  Here's the summary:

"Technologies that have received regulatory approval from the FDA often lack sufficient scientific data to convince commercial insurers to pay for them. Without support from commercial payers, it is difficult for new innovations to influence the practice of medicine.

"VITAL’s mission is to leverage Highmark Health's position as one of the largest integrated health care delivery and financing systems in the nation to accelerate the pace with which novel technologies and services are made available to our customers. In doing so:
• Members and patients will be afforded access to safe new technologies without undue financial burden.
• Payers will be able to understand the full impact of new technologies on their members without changing insurance medical policy prematurely.
• Providers will gain early access to novel technologies and a first-hand understanding of their impact on patients.
• Technology vendors will have the opportunity to prove the benefits of their new innovations to patients, providers and payers.


"The VITAL innovation program is essentially a test bed designed to facilitate early use of technologies that have received regulatory approval and are being used for their intended purpose within the approved patient population but are not yet covered by most commercial insurers. VITAL is designed to provide the missing link between FDA approval of an innovative technology and its full reimbursement."

This is interesting.  I view this program as a mechanism to moderate the tension between a desire to get new technologies out quickly and analyzing the clinical efficacy and cost effectiveness of those same technologies.  This will be a good one to watch over the coming months and years.

Tuesday, July 21, 2015

$300 million misplaced in NYC

If you were going to invest $300 million in the health care of New York City residents, how would you spend it?  In an era of "population health," would you spend it on a single 115,000-square-foot project to provide proton beam therapy?

Well, that's what Memorial Sloan-Kettering Cancer Center, Montefiore Medical Center, Mount Sinai Hospital and ProHEALTH, a multi-specialty physician group practice, are doing.

Construction of the VOA Associates-designed complex will begin this summer with the first patient expected to receive treatment in the spring of 2018. Goldman Sachs and JPMorgan Chase & Co. provided financing.

The beat goes on. How many more of these do we "need?"

Great Scott! David's right again.

I met David Meerman Scott many years ago and was impressed with his perspicacity regarding social media.  He was a man ahead of his time in understanding the potential for these new platforms to reach out inform, and entertain--as well as to waste your time!

Even now, he regularly produces gems of insight.  Here's one from just a few days ago. A teaser:

Social networks are a great place to share content, to interact with others, to listen in on what’s happening, and yes, if approached carefully, social networks can be a way to get the word out about you and your business. However as I review people’s business-related social streams I find way too much selling going on.

As a way to think about your social activities, I’d suggest you should be doing 85 percent sharing and engaging, 10 percent publishing original content, and only five percent or less about what you are trying to promote.

If you are trying to sell, it's well worth your while to read the rest.