#MEQAPI – Tweetchat May 11th 2017 3:00ET: Malta #eHealthWeek

Topic:  Joint #MEQAPI and  chat

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

Chuck Webster M.D. blogged on the joint #MEQAPI  and #eHealthWeek chat, but from a Quality Improvement perspective, we could keep the following in mind while looking at the topics:

 

    • Methods
      • Policies: office, organization, or national policies, including MU, HIPAA, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Insurance Models, payer systems
      • Vendor policies and processes
      • Home visits
    • Machines (equipment, EHR)
      • Medical or office equipment
      • Home equipment specific to the patient condition
      • Integration/interoperation with other office or medical systems, or user personal health records
      • Medication dispensing systems
    • People
      • Staffing: sufficient and qualified staff
      • Training: base training, ongoing training, CME, and patient or carer training
      • Attitudes: staff attitudes to technology, adoption vs resistance
      • Fatigue (especially alert fatigue)
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • Drug information sheets
    • Measurement
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc.
      • Monitoring of home-care
      • Adverse Effects reporting
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient

Participants are invited to describe their experiences of medication errors, and offer their insights and observations.

Topics

  1. #Malta has a national patient ID. Advantages? Disadvantages? Should US do the same?
  2. Europe healthcare is predominately single payer. What are/would be, implications for health IT?
  3. EU has 28 nations & 24 languages. US is becoming more diverse. How does culture influence HIT?
  4. Do any US based #MEQAPI regulars have questions for any #eHealthWeek attendees? Visa-versa?
  5. #MEQAPI regulars, quick, look at recent #eHealthWeek tweets, your favorite? Visa-versa?
  6. Workflow is a global & universal healthcare concern. It’s also incredibly localized. Discuss!

 

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

 

 

 

Advertisements

#MEQAPI – Tweetchat May 4th 2017 3:00ET: Medication Errors

Topic:  Quality Improvement vs Medication Error

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

Medical error is arguably the third leading cause of death in the US, and while many arguments can be made that the underlying research is imperfect, it is clear that medical error is still one of the leading causes of untimely death. One of the primary causes of the high death rate is medication errors.

Medication errors result in missed opportunities, injury, and death. When the incorrect dose, incorrect medication, or wrong patient are in play, harm often results. Harm can also occur when incompatible combinations of drugs are administered – either because one drug reduced the efficacy of another, or because they worked similarly and resulted in an effective overdose.

In an attempt to reduce drug-related harm, vendors and providers have tried many different fixes – ranging from making the fonts more readable, to electronic drug-drug interaction checks, to dispensing robots. The results have ranged from inconclusive to significant, but as yet no approach or combination of approaches has yet removed medication errors from the list of top causes of medical error resulting in harm.

Some supporting reading for the chat comes from Physician’s Weekly:

An additional resource is the report by the LeapFrog group on the use of bedside barcoding for medication dispensing.

We will take a QI approach, and discuss the  topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

MEQAPI Medication Error

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

    • Methods
      • Policies: office, organization, or national policies, including MU, HIPAA, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Insurance Models, payer systems
      • Vendor policies and processes
      • Home visits
    • Machines (equipment, EHR)
      • Medical or office equipment
      • Home equipment specific to the patient condition
      • Integration/interoperation with other office or medical systems, or user personal health records
      • Medication dispensing systems
    • People
      • Staffing: sufficient and qualified staff
      • Training: base training, ongoing training, CME, and patient or carer training
      • Attitudes: staff attitudes to technology, adoption vs resistance
      • Fatigue (especially alert fatigue)
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • Drug information sheets
    • Measurement
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc.
      • Monitoring of home-care
      • Adverse Effects reporting
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient

Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.

Topics

  1. What Methods increase or reduce the risk of medication errors
  2. What Machine factors increase or reduce the risk of medication errors
  3. What People issues increase or reduce the risk of medication errors
  4. What Materials increase or reduce the risk of medication errors
  5. What Measurement factors increase or reduce the risk of medication errors
  6. What Environmental factors increase or reduce the risk of medication errors

MEQAPI Numbers May 4 2017

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

 

 

 

#MEQAPI – Tweetchat April 27th 2017 2:30ET: EHR Success Story

Topic:  Quality Improvement vs EHR Success Story with James Legan MD

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

This chat is about using an EHR to improve practice and patient experience.

The HITECH, ARRA, and Meaningful Use programs greatly accelerated adoption of electronic health record (EHR) systems by providers. Adoption by office-based providers rose from 21%  in 2004, to 87% by 2015. Many will, however, say that the cost was too high, the results too poor, and that it has potentially soured an entire generation of providers to the idea of Health IT solutions in general and EHR in specific.

While this may be true, there is considerable variation in outcomes and realized value, and wherever there is variation, there is opportunity for quality improvement. For some, the EHR is a frustrating waste of time that is added to an already cramped schedule, and represents an additional burden of several hours of duplicitous administrative work at the end of each workday. For many, the EHR is just another administrative chore. For a few, the EHR has reduced administrative work, improved efficiency, and supportedthe ability to serve patients.

This week the #MEQAPI topics relate to a specific healthcare provider’s experience that may be seen as a positive outlier. Dr. Legan has put together a solution that pairs an EHR and a CRM, and has seen improvements that many would envy. Dr. Legan is an Internal Medicine Physician, in his 23rd year in Private Practice in Great Falls, Montana.Great Falls is in the North Central Montana region, and has approximately 50,000 population, served by two large multi-specialty hospitals. The practice is outpatient-only, and consists of eight physicians: three Internists, four Family Practice, and one Pediatrician, each with approximately 1,200-2,000 patients. Ancillary staff includes five shared in-house billing staff, and each physician has one to three additional support staff.

Dr. Legan has a patient-facing display so that the patient sees everything in the EHR as it is being reviewed or entered.

legan

Dr. Legan describes his outlook on EHR as follows:

I am convinced the electronic health record (EHR) needs to be shared as a visual interactive medium at the point of care.  The primary role of the EHR should be educational, all other uses secondary.  I discuss this approach #ProjectedEHR on twitter.

Videos of #ProjectedEHR I Periscoped to You Tube

  1. https://www.youtube.com/watch?v=moTXADdpHtU (me being interviewed)
  2. https://www.youtube.com/watch?v=HOlKbl1dAWE(interviewing a patient)
  3. https://www.youtube.com/watch?v=EA5X_LP5_PQ (Wall mounted TV/chromebook)
  4. https://www.youtube.com/watch?v=kz9rVtRpuI0 (Dual monitored desktop/chromebook in office carried to exam room)

#ProjectedEHR–User friendly EHR that projects well, 14 inch Chromebook, 24 inch TV, 10 foot HDMI cord, 8 inch HDMI extender, wall mount, remote access application made for chrome & encrypted (VNC viewer made for Chrome, Enterprise Version).  The chromebook simulates my dual monitored desktop, so I take my “virtual desktop” into the exam room and plug in the HDMI cord to extender and the learning begins.  Always check with your IT support to make sure everything is HIPAA compliant and secure.

Some supporting reading for the chat comes from Physician’s Weekly:

We will take a QI approach, and discuss the  topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

MEQAPI EHR

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

    • Methods
      • Policies: office, organization, or national policies, including MU, HIPAA, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Insurance Models, payer systems
      • Home visits
      • Charting – automatic vs manual
    • Machines (equipment, EHR)
      • Medical or office equipment
      • Home equipment specific to the patient condition
      • Integration/interoperation with other office or medical systems, or user personal health records
    • People
      • Staffing: sufficient and qualified staff
      • Training: base training, ongoing training, CME, and patient or carer training
      • Attitudes: staff attitudes to technology, adoption vs resistance
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
    • Measurement
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc.
      • Monitoring of home-care
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: ergonomic requirements of system- maybe leading to cramped, uncomfortable work space etc.
      • Time: Too little time per patient, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient

Dr. Legan will be responding to the following topics with regard to his own system, and will field questions from other participants. Participants are also invited to respond with regard to their experiences of EHRs, and offer their insights and observations.

Topics

  1. What risks, issues, opportunities, or observations did you have related to Methods and your EHR/CRM solution
  2. What risks, issues, opportunities, or observations did you have related to Machines and your EHR/CRM solution
  3. What risks, issues, opportunities, or observations did you have related to People issues and your EHR/CRM solution
  4. What risks, issues, opportunities, or observations did you have related to Materials and your EHR/CRM solution
  5. What risks, issues, opportunities, or observations did you have related to Measurements  and your EHR/CRM solution
  6. What risks, issues, opportunities, or observations did you have related to Environment issues and your EHR/CRM solution

 

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

 

 

 

#MEQAPI – Tweetchat April 20th 2017 3ET: Quality Improvement vs Patient Readmission

Topic:  Quality Improvement vs Patient Readmission

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

This chat is about patient readmission.

Re-admissions within 30 days of  discharge often result from patient harm, and may result in payment clawback from insurance providers, Medicare, Medicaid, etc. Readmission may reflect a quality issue,  and as such, readmission often acts as a signal that something went wrong – something was missed, something caused harm, etc.

There are many different risks, issues, and opportunities related to patient readmission, including patient knowledge deficits, home care, weekday vs weekend discharges, self-care, and dealing with complex patient comorbidities and home/work environment.

This week the #MEQAPI topics relate to Physician’s Weekly articles related to readmission::

The period immediately following discharge is associated with several heightened risks, and has a very high need for patient or carer participation – if the patient doesn’t fully understand their post-discharge duties, needs, and risks, there can be significant harm, resulting in readmission or even post-discharge mortality. Readmission may also be due to indirect issues, such as self-harm. The period immediately following discharge carries a high risk for suicidality.

Standardizing the patient discharge process and making it a “no interruption” activity can reduce readmission risk, but readmission may be due to a wide range of causes, including the patient or carer not having the knowledge or means to carry out ongoing care. 

Quality Improvement approaches can greatly reduce readmission risk by identifying what works and observing what doesn’t work, and intervening in an effective and timely fashion to refine the discharge process and remove risks.

We will take a QI approach, and discuss the  topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

MEQAPI Readmission

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

  • Methods
    • Policies: either unit, office, organization, or national policies
    • Workflow: how things are done that might increase risks of errors, or harm the patient, or create gaps self-care, etc.
    • Insurance Models
    • Home visits
    • Transportation option
  • Machines (equipment, EHR)
    • Medical or office equipment that might increase risk: old, broken, poorly installed, etc.
    • Home equipment specific to the patient condition
    • Software systems (especially EHR?), that might lead to duplicate work, frustration, cause medical errors like wrong pt, wrong site, wrong meds, and create hours of extra work per day.
  • People
    • Staffing: insufficient or unqualified staff
    • Training: insufficient base training, incorrect training, insufficient CME, etc. or insufficient patient or carer training
    • Attitudes: staff attitudes e.g. paternalism, rudeness, and workplace bullying.
  • Materials
    • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
    • Supplies: medical or office, inferior fax paper, lack of coffee(!)
    • Data? – sent to wrong recipient, not shared with pt or specialist, etc.
    • Patient self-care materials including checklists and how-to instructions, contact information for questions, and slef-care consumables
  • Measurement
    • KPIs: operational metrics that focus on the wrong things, or are poor measures, and that drive wrong behavior
    • Poor quality and safety metrics
    • Targets: improper or unachievable performance targets
    • Incentives: improper, biased, or discriminatory rewards, conflicting or perverse
    • Monitoring of home-care
  • Environment
    • Noise: distracting noises, sound levels too high, etc.
    • Space: cramped, uncomfortable, slippery surfaces, etc.
    • Time: Too little time per patient, too little time in a day, too many demands
    • Location: things not where they should be, too much movement of staff, pt, or equipment needed, etc.
    • Readiness of receiving point of care to cater to patient needs

The aim of this chat is look at each of these dimensions of causation, and discuss what we have seen before that has been a risk or developed into burnout, or that we anticipate is likely to become an issue.

  1. What Methods (policies, workflow, etc) have you seen or anticipate may increase risk for a readmission
  2. What Machines (med/office equipment, EHR/SW) have you seen or anticipate may increase risk for a readmission
  3. What People issues (staffing, training, bullying) have you seen or anticipate may increase risk for a readmission
  4. What Materials (forms, supplies, data?) have you seen or anticipate may increase risk for a readmission
  5. What Measurements (KPIs, targets, incentives) have you seen or anticipate may increase risk for a readmission
  6. What Environment issues (noise, space, time) have you seen or anticipate may increase risk for a readmission

 

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

 

 

 

#MEQAPI – Tweetchat April 13th 2017 3ET: Quality Improvement vs Patient Discharge

Topic:  Quality Improvement vs Patient Discharge

This chat is over, but you can see the #MEQAPI storify thread

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

This week the #MEQAPI topics relate to British Medical Journal and Physician’s Weekly articles related to safe and effective patient discharge.

Patient handoff and discharge are two of the most risky events in the patient journey through the care process, and account for the lion’s share of mistakes and missed opportunities. Incomplete or incorrect information transfer, (or failure to transfer at all) can result in sub-optimal patient outcomes, injury, or death.

There are many different risks, issues, and opportunities related to patient discharge, including patient knowledge deficits, home care, weekday vs weekend discharges, self-care, and dealing with complex patients.

Standardizing the patient discharge process and making it a “no interruption” activity can reduce risks due to distraction, multitasking, and missed steps, while also reducing missed opportunities. Patient discharge also has a very high need for patient or carer participation – if the patient doesn’t fully understand their post-discharge duties, needs, and risks, there can be significant harm.

Quality Improvement approaches can greatly increase adoption and effectiveness of standardized discharge processes by identifying what works and observing what doesn’t work, and intervening in an effective and timely fashion to refine the discharge process and remove obstacles to adoption and compliance.

We will take a QI approach, and discuss the next topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

MEQAPI Discharge

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

  • Methods
    • Policies: either unit, office, organization, or national policies
    • Workflow: how things are done that might increase risks of errors, or harm the patient, or create gaps in discharge, etc.
    • Insurance Models
  • Machines (equipment, EHR)
    • Medical or office equipment that might increase risk: old, broken, poorly installed, etc.
    • Software systems (especially EHR?), that might lead to duplicate work, frustration, cause medical errors like wrong pt, wrong site, wrong meds, and create hours of extra work per day.
  • People
    • Staffing: insufficient or unqualified staff
    • Training: insufficient base training, incorrect training, insufficient CME, etc.
    • Attitudes: staff attitudes e.g. paternalism, rudeness, and workplace bullying.
  • Materials
    • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
    • Supplies: medical or office, inferior fax paper, lack of coffee(!)
    • Data? – sent to wrong recipient, not shared with pt or specialist, etc.
  • Measurement
    • KPIs: operational metrics that focus on the wrong things, or are poor measures, and that drive wrong behavior
    • Poor quality and safety metrics
    • Targets: improper or unachievable performance targets
    • Incentives: improper, biased, or discriminatory rewards, conflicting or perverse
  • Environment
    • Noise: distracting noises, sound levels too high, etc.
    • Space: cramped, uncomfortable, slippery surfaces, etc.
    • Time: Too little time per patient, too little time in a day, too many demands
    • Location: things not where they should be, too much movement of staff, pt, or equipment needed, etc.

The aim of this chat is look at each of these dimensions of causation, and discuss what we have seen before that has been a risk or developed into burnout, or that we anticipate is likely to become an issue.

  1. What Methods (policies, workflow, etc) have you seen or anticipate may increase risk for a bad patient discharge
  2. What Machines (med/office equipment, EHR/SW) have you seen or anticipate may increase risk for a bad patient discharge
  3. What People issues (staffing, training, bullying) have you seen or anticipate may increase risk for a bad patient discharge
  4. What Materials (forms, supplies, data?) have you seen or anticipate may increase risk for a bad patient discharge
  5. What Measurements (KPIs, targets, incentives) have you seen or anticipate may increase risk for a bad patient discharge
  6. What Environment issues (noise, space, time) have you seen or anticipate may increase risk for a bad patient discharge

 

meqapi number april 13

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

 

 

 

The Three Horsemen of the Coming Healthcare Apocalypse

Ok, so not really – It’s not about horsemen, it’s already partially here, and it won’t be an apocalypse either. It is however going to be a very big problem, it’s going to bankrupt some people, destroy some industries, and it’s going to put a massive hurt on almost everybody for many decades to come.

There are three healthcare issues that interact with each other, and which would have been a huge problem individually, but are going to slap us hard across the face when put together. I am talking about the Aging Population, Obesity, and Climate Change.

Aging Population

Here’s the thing. 10,000 Boomers are retiring per day, they did a horrible job of preparing the next generation to take the helm, and there are fewer of the next generation to do so anyway. We already have a looming shortage of nurses and doctors and medical technicians, and when a bolus of them retire and need medical help, we simply won’t have enough replacements to take care of the aging population. If your organization didn’t have a knowledge management, and training and recruitment plan already in motion ten years ago, the bottom line is that it’s too late. The chances are that you won’t save your organization from collapsing, and the best you can do is arrange a slightly more elegant landing than a straight-up belly flop from the highest diving board.

The medical schools have been focused on keeping profits high, the APA on keeping competition down, and who in heck knows what legislators were doing. Probably nothing. Maybe just pulling practical jokes on each other. So we have let the Magic Sparkle Fairy of the Invisible Market and siloed interests and perverse incentives drive how we scaled, staffed, and recruited for medical schools, and we are going to be massively, monstrously, marvelously short. We are already short, and it gets worse.

We are going to have the same problem across every part of healthcare, and our normal go-to plan of stealing skills from other countries isn’t going to work because they have the same problems.

That was the good news.

The bad news is it’s going to be much, much, much worse than I said. We didn’t invest in the infrastructure or save for this either, so this is going to be a huge, nasty drag on getting anything done in healthcare.

Obesity

The entire world is getting heavier, and the US is one of those leading the charge. I mean of course the people are getting heavier. All ages, all genders, all races. All income groups. Some a bit more than others, but all of them are slowly getting heavier. Actually, not so slowly. Kinda fast. In fact, very fast – the rate has doubled globally since 1980. Obesity is now something that 35% of Americans can call their own, and the number is climbing.

With obesity comes a rapid increase in a whole raft of medical conditions, including diabetes, coronary disease, cancer, depression, and so on. All of them very expensive, chronic, and thoroughly entangled in social determinants of health and perverse incentives. One example is that we subsidize corn production. That creates cheap corn syrup. Corn syrup is added to every food and drink imaginable. It contributes to obesity, diabetes, stroke, and tooth decay. Wonderful stuff. So we fund a thing that kills us. Wonderful. We do that a lot.

We have entire industries whose focus is to craft very unhealthy food that is very appealing to our instincts, the way our brains work, and are kinda habit forming. The more money they make, the sicker we get, and they like making more money.

Climate Change

Despite Congress being really conflicted over whether it is happening, whether we are causing it, whether it is more important to bring out tortuous laws about gender assignment and public restrooms, Climate Change is increasingly a topic in healthcare. The anticipated effects of Climate Change of healthcare can be seen in research papers, conference sessions, and lectures at medical schools. The news isn’t very good. Well, actually not “good” as much as really bad.

There is almost no healthcare problem that is not made worse by Climate Change. On its own, Climate Change would be a darned pest. It will disrupt the agricultural supply chains, submerge some of our business transport links and cities, and increase damage to infrastructure through storm surges, hurricanes, tornados, and other forms of interesting peak weather. However, that’s just the entertaining stuff. It will also lead to resurgence of old medical enemies, shift vectors into novel regions, and hike up emergency visits for everything from asthma to zoonotic infections.

Conclusion

So even together these three aren’t an apocalypse, and won’t end the planet, our species, or even halt the amount of sports we watch. From the couch. With a Big Mac and Fries. And a soda. A big one. The super-slurp one that’s five times the size of our bladders and has enough corn syrup to kill off a platoon of insulin-producing beta cells. Not an apocalypse.

While it won’t be an apocalypse, each one will be a bit like getting a backhander through the face. On a cold morning. With a fish. A large wet fish. The three together will be like getting three individual fishy-slaps through the face, followed by another, bigger fish. With spines and slime. And frozen. A hearty backhander though the face on a cold morning with a large frozen fish, wielded by an Olympic medalist in fish throwing.

A bit like that.

Are you ready?

Utilization Management and Climbing Healthcare Costs

With all the attention that the soaring cost of healthcare has been getting over the last few election cycles, it’s easy to assume that this is a new phenomenon, and that back in the “old days”, it wasn’t a concern.

Quoting my own previous papers on the topic: The actual  history of healthcare and cost is different, however, and the rising cost of healthcare has been an issue in the US since the early 1920’s, and led to the formation in 1927 of the Committee on the Costs of Medical Care.
Although health insurance firms had been concerned over high medical costs which they identified as being at least partly the result of unnecessary procedures and hospital stays, it was the creation of the Social Security Act of 1965 for Medicare and Medicaid Title XVII and XIX that provided the impetus for a focus on methods to standardize admission and hospital stay decisions.

During this time, there was significant variation between physicians, hospitals, and regions on the use of procedures or inpatient admissions, and it was typical for patients to be admitted for weeks or even months for observation or for procedures that would currently require less than a week or even be performed on an outpatient basis.

The Social Security provisions required clinical evaluation and review, but did not set criteria. In the early 1970’s a Congressional subcommittee estimated that were over two-million unnecessary surgeries per year across the US. As a result, there was a growing requirement for standards regarding procedures and inpatient admissions. [1]

To give a context of scale, physicians who fail to follow evidence-based clinical criteria add a $500 billion cost burden to U.S. healthcare by providing overly aggressive or ineffective care. [2] In a study of contribution to cost by cases that do not meet clinical guidelines, Cutler et al found that patient demand was not a significant contributor, but that physician preferences unsupported by clinical evidence accounted for 36%  of end-of-life spending, and 17% of total health care spending. [3]

One approach to reducing costs and controlling the “exuberance” of a free market that would naturally tend towards increasing use of medical products and services, is to have clinical episode of care criteria. Utilization Management criteria can be used prior to encounters  (prospective review), as part of the triage and episode of care decisions (concurrent review), or as a quality improvement tool to assess episode of care after the case (retrospective review).

With this backdrop of cost burden, it is clear that UM plays a critical role in provision of appropriate care. UM adds value by reducing the incidence of unnecessary care, and by placing the patient at the most appropriate level of care with the least possible delay. Effective UM supports efficient scheduling of inpatient admissions and procedures by reducing the number of unnecessary admissions, and providing an evidence-based mechanism for admission decisions. Modern UM balances Cost vs. Care through a systematic process and evidence-based criteria.

References
1. Field, M. J. (1989). Controlling costs and changing patient care?: the role of utilization management. National Academies.
2. Goldberg, C. ‘Cowboy’ Doctors Could Be A Half-A-Trillion-Dollar American Problem, 2014.
3. Cutler, D. Skinner, J. Stern, D. and Wennberg, D. “Physician beliefs and patient preferences: a new look at regional variation in health care spending,” National Bureau of Economic Research, 2013.