Save Money and Reduce Medical Errors

and improve the quality of healthcare!
HealthImaging featured a report Medical errors cost U.S. $17 billion in 2008 which estimated that

This figure amounted to 0.72 percent of the $2.39 trillion spent on healthcare that year in the U.S.

The study identified the sources based on medical claims estimating:

564,000 inpatient injuries (1.5 percent of all inpatient admissions in the U.S.) and 1.8 million outpatient injuries (0.15 percent of the estimated outpatient encounters nationwide)

Given the landmark publication "To Err is Human" from the IOM from November 1999 that estimated at that time:

...total costs (in­cluding the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide.

the progress remains frustratingly poor more than 10 years on. There is a top 10 list featured in the latest research that accounted for 69% of the costs

• Postoperative infections were the most costly error, ($3.3 billion)
• Pressure ulcers ($3.2 billion)
• Mechanical complications of noncardiac device implant or graft ($1 billion)
• Postlaminectomy syndrome ($995 million)
• Hemorrhage complicating a procedure ($678 million)
• Infection due to central venous catheter ($589 million)
• Pneumothorax (collapsed lung) ($569 million)
• Infection following infusion, injection, transfusion or vaccination ($566 million)
• Other complications of internal prosthetic device, implant and graft ($398 million
• Ventral (abdominal) hernia without mention of obstruction or gangrene ($342 million)

The list serves as a focal point for healthcare professionals and patients that offer significant opportunity for improvement in both costs and quality of care. With the announcement of Accountable Care Act (ACO) on March 31 by HHS will further focus the healthcare system on removing errors and delivering a more complete and holistic approach to care. There has been much written about the ACO concept with many commentators suggesting that organizations and healthcare facilities are not ready for these changes. I would suggest that we can neither afford as providers nor accept as patients any delay in a move towards fully accountable care that focuses on on putting the doctors and patients in better control of their care and linking reimbursement to outcomes

Evidence Based Medicine, Medical Malpractice and Incentives

A recent Dustin Comic like all good comics hit the proverbial nail on the head



Unfortunately the healthcare reform fails to address key aspects to the incentive problem in healthcare. The system remains centered on measuring what we do for patients rather than the end result.

There are moves by employers and the insurance industry to incentives patients towards healthier behavior. This approach is not without problems as highlighted in this piece in the New England Journal of Medicine "Carrots, Sticks, and Health Care Reform — Problems with Wellness Incentives" where the authors highlight the challenges for employers, employees and insurance in creating incentive and how this can introduce inequities that do more harm than good. As they point out

If people could lose weight, stop smoking, or reduce cholesterol simply by deciding to do so, the analogy might be appropriate. But in that case, few would have had weight, smoking, or cholesterol problems in the first place

There is no doubt that patient incentives must be part of the solution but require thoughtful design and implementation to avoid the pitfalls

Incentives for healthy behavior may be part of an effective national response to risk factors for chronic disease. Wrongly implemented, however, they can introduce substantial inequity into the health insurance system. It is a problem if the people who are less likely to benefit from the programs are those who may need them more.

But incentives aligned to the practice of evidence based medicine and in particular the financial challenges facing the ever increasing ordering of tests is where there seems to be significant progress. The announcement of a statewide adoption of Radport by the Institute of Clinical Systems Improvement (ICSI), a nonprofit comprising 60 medical groups, 9,000 physicians, and six payers and health plans was covered extensively at RSNA 2010 in Chicago this year and featured in this piece in Information Week "System Helps Doctors Pick The Right Tests" demonstrating a saving of $27 Million over the preceding year

During the yearlong pilot involving more than 2,300 ICSI-member physicians, ICSI saw no growth in the number of high-tech diagnostic imaging tests ordered. In previous years, the number of tests ordered grew about 8% annually...The lack of growth translates to a savings about $28 million for the year

But any discussion on incentives needs to include the issue of malpractice - liability drives behavior in the same way as incentives do (in some respects its incentive in another from). Peter Orszag opinion in the NY Times Malpractice Methodology makes the point that

The health care legislation that Congress enacted earlier this year, contrary to much of today’s overheated rhetoric, does many things right. But it does almost nothing to reform medical malpractice laws. Lawmakers missed an important opportunity to shield from malpractice liability any doctors who followed evidence-based guidelines in treating their patients.

President Obama weighed in on this issue in June 2009 when he spoke to the American Medical Association when he highlighted the "unnecessary tests and treatments (ordered by doctors) only because they believe it will protect them from a lawsuit" and as he put it

We need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine and encourage broader use of evidence-based guidelines

Medicine remains "more evidence-free" than should be the case:

One estimate suggests that it takes 17 years on average to incorporate new research findings into widespread practice

Addressing the issue of liability can take the traditional approach of limiting punitive damages but as Peter Orszag said "provide safe harbor for doctors who follow evidence-based guidelines" is a much better idea and one that would sit well with patients and doctors alike (I'd be interested to hear from lawyers who agree or disagree on the merits of such an approach).

There are some initial moves in this direction and a need to implement technology to help guide the treatment (as we see with ICSI) and all this would also lead to higher quality of care for everyone and possibly a new system that reimbursed based on the quality of care delivered versus the quantity of care.

Radiology Examinations - How Much is Too Much

As is often the cases conflicting information in the media on the benefits of screen, x-rays and healthcare.
This piece in the NY Times: CT Scans Cut Lung Cancer Deaths, Study Finds suggests that annual CT Scans of current and former smokers reduces the risk of death form lung cancer:

Annual CT scans of current and former heavy smokers reduced their risk of death from lung cancer by 20 percent, a huge government-financed study has found. Even more surprising, the scans seem to reduce the risks of death from other causes as well, suggesting that the scans could be catching other illnesses.

And while there does seem to be some benefit as Dr Patz (professor of radiology at Duke who helped devise the study) put it:

he was far from convinced that a thorough analysis would show that widespread CT screening would prove beneficial in preventing most lung cancer deaths. Dr. Patz said that the biology of lung cancer has long suggested that the size of cancerous lung tumors tells little about the stage of the disease. “If we look at this study carefully, we may suggest that there is some benefit in high-risk individuals, but I’m not there yet,” Dr. Patz said.

And before you run out the door to get your CT scan its worth taking note of Dr Ben Goldacre's insightful blog Bad Science that takes a hard look at the science behind claims and does a great job debunking the myths and taking a hard look at statistics. But as we have seen over the last few months there is an increasing focus on excessive use of imaging technologies. Earlier this year the Imaging e-Ordering Coalition (Co Chaired by our very own Scott Cowsill) Successfully made a case to congress to include computer-based physician order entry (CPOE) solutions as a potential method for imaging utilization management in recently passed health care legislation:

the Coalition is making several recommendations to policy makers in Congress and CMS...One of the recommendations is that imaging CPOE tools should be based on consensus medical guidelines and literature, such as the ACR's appropriateness criteria. Another recommendation is that CPOE and decision support tools should be compatible with any CMS-approved electronic medical record (EMR) systems and be able to track results.

In recent news the Healthcare alliance aims to improve the imaging process, Changing the Game the coalition continues to push for

E-Ordering, also referred to as clinical decision support (CDS) (to) provide(s) physicians with real-time, electronic access to pre-exam, case-by-case decisions linked to evidence-based clinical guidelines and tailored to a patient’s specific circumstances

and cites a 7-year study at MGH (pub 2009) that showed a dramatic decrease in the growth rates of several imaging exams

• CT exams down from 12% growth to 1%
• MR exams down from 12% dropped to 7%
• Ultrasound down from 9% to 4%

So with that in mind the concurrent news that Minnesota’s Institute for Clinical Systems Improvement (ICSI) is spearheading the First Statewide Effort to Help Ensure Patients Receive Appropriate High-Tech Diagnostic Imaging Tests that is targeted to save Minnesota healthcare community more than $28 million annually (this was the savings estimated from the year long pilot with 2,300 physicians from five Minnesota medical groups, five health plans taking part. You can read more about it here, and here in the Star Tribune in Minneapolis St Paul and here on ZDNet

The process and challenges are outlined in this video:



Showing how you can help the busy clinician by providing them with a simple, intelligent and above all standardized appropriateness criteria to guide the clinician in ordering the most appropriate study for the patient at the time of consultation. This improved patient satisfaction, clinic efficiencies and reduced administrative costs. While there will be those who distrust technology over seeing clinical decision making the solution does not force or prevent clinicians from ordering the test they deem the most appropriate. What it does do is provide evidence based guidance on the suitability or clinical appropriateness of the test.

How do you feel as a patient or as a clinician on technology guiding care choices? Like it or not expect to see more as we continue to cope with a veritable Tsunami of clinical data, studies and discoveries that by some estimates require a doctor to read for 70 hours per week just to keep up in their one speciality.

Redesigning Medicine

Through provoking piece in the Washington Post today - Health Reform's Next Test by Jim Yong Kim and James N Weinstein at Dartmouth Hitchkcock. As they state

It is well known that U.S. health-care costs, as a share of our economy, are the highest in the world but that compared to other industrialized countries, our results are the worst. The Dartmouth Atlas has documented the enormous waste in our system and shown that spending more money and performing more medical procedures do not equal better outcomes for patients.

So true and so troubling as health reform marches forward under the new law. We do deserve good care and the blame storming that continues to affect all the efforts is counter productive and as they point out

We cannot blame government or insurers or physicians for the complex and multilayered problem. No single group or entity created the puzzle that is our health-care system; it is not reasonable to expect one group to solve it

Their use case shines a spot light on the challenges we face

Consider the moving pieces of a patient-health system encounter. A patient comes into the emergency room. Immediately, judgments are made about how sick she is and what treatments she needs. There is no universal medical record for that patient, so the provider has no idea about her medical history, medication use or preexisting conditions. Incomplete information is relayed through layers of nurses, physicians, specialists and the shifts of personnel who replace them. In the absence of real-time information, tests are ordered and treatment decisions made. Perhaps after an overnight stay, barring complications from drug interactions or perhaps an unrecognized underlying condition, she is discharged, with no further transfer of information to a provider and, more important, no follow-up to see whether the treatment was effective

But it is this summary point that amplifies the point:

The symptoms were treated; the patient was not.

This is exactly the point and their attempt to set up the "Center for Health Care Delivery Science" is one step int he process of many that needs to start with a realistic look at the challenges we face and the need for everyone to be part of the solution and not part of the problem.

Mixed Results from Healthcare IT Technology

In an interesting article in HealthAffairs this month "Mixed Results In The Safety Performance Of Computerized Physician Order Entry" (abstract only - subscription required for full article) the authors carried out a simulation of Computerized Physician Order Entry (CPOE) effectiveness.

It is a unique study with a relatively small sample size (62 facilities) that was self selecting that does represent some bias through small sample size, self selection and simulation vs reality. All that said there is still a surprising conclusion that

Many hospitals only detected 44% of adverse drug events and the best performing only detected 70-80%.

Not only is this wide variation and poor results for a very costly highly disruptive technology that is mandated in meaningful use. There is a clear need to validate the value of technology that is being suggested and especially if it is being mandated in the complex world of healthcare

These are, as many folks have commented to me  "very interesting times" but lets not loose sight of the science that formed the basis of some of the most significant advances in medicine encompassed in Randomly Controlled Trials.

Does your experience vary. Have you seen the value of CPOE or has it been a challenge in your facility?
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