Telemonitoring at VNHS

The demand for home health is expected to increase to 15 million by 2020 due to the aging baby boomer population. The Visiting Nurse Health System (VNHS) case discusses the benefits of providing telemonitoring services to at-risk patients who were discharged from hospitals and need home care, and the difficulty quantifying those benefits.

Comment and build on what others say about VNHS, the services it provides, and whether you think home health systems like Health Buddy will increase medication compliance and reduce outpatient visits.  Explain your thinking.  Is it a benefit to the patients?  To VNHS?  You can speak to the case as well as other sources that speak to this issue.

Health IT Usage Behavior and Patient Safety

I recently read a report that offered a theoretical model of health it usage behavior and implications for patient safety.   The authors chose to focus on theories that could explain clinician HIT usage behavior because of the widely observed underuse and misuse of HIT and the associated patient safety consequences.  They claim it is important to understand that poor system design, through its effect on behavior, is the root of the problem.  That is, poorly designed systems facilitate or even encourage behaviors that may be contrary to expectations, policies or goals, and the models presented here make clear that the exogenous variables are system design factors.


Perhaps the most obvious case of a HIT whose efficacy suffers from underuse is that of medical error/incident reporting systems: upto 96% of medical errors are estimated to go unreported. Briefly, reporting systems are paper-based or electronic systems used by health care providers to report in some detail the occurrence of safety-related events. These events, depending on the system, may be instances of patient harm, near-misses, preventable errors that lead to harm, detected hazards that may lead to future harm, or combinations of these. Although reporting can have various purposes, the two main ones are learning and system improvement. As an example, consider a health care organizations that foster a culture of blame and shame, not only are needs not being met, but reporting may threaten vital needs. This is illustrated in Figure 1 below, where primary needs on the hierarchy are jeopardized when one reports in a blame culture. Examining Figure 1 provides a motivational explanation as to why many studies find that fear of punitive consequences deters many clinicians from reporting, whereas ethical obligations, small rewards, and a positive reporting culture tend to be motivators.

Figure 1. Needs met and jeopardized by the reporting of medical errors in a blame culture 

Here is a video that explains what happens when cultures move from blame to identifying root causes of the problem.

Moving Away from Fee-for-Service

Even though there are many advances in healthcare innovation, if American health care continues to use the outdated fee-for-service (FFS) model of paying for care, it is expected that by 2020, health care will consume 19.8 percent GDP.  If we paid for high quality care, it might be worth it, but Americans are not receiving recommended care and nearly half of all Americans suffer from chronic disease such as diabetes or hypertension.
In a FFS model, payers reimburse for all services, regardless of their impact on patient health. Little or no countervailing pressure to discourage the delivery of unnecessary services exists in this system. While most patients are shielded from the direct cost of care by insurance, the fear of lawsuits ("defensive medicine") encourages doctors to order any and all tests.

How it Began

During the years prior to WWII, fee-for-service originated as "traditional indemnity" health insurance--you get a service, submit your claim, and your insurer covers your incurred expenses. What used to be called "managed care" emerged around the same time, as prepaid insurance plans. In a prepaid plan, beneficiaries pay a set premium in return for care from a defined network of providers.

Unfortunately, managed care ultimately failed to control health care costs, and increasing restrictions on care led to a political backlash in the late 1980s and 1990s. While managed care plans grappled with increasing cost pressures, providers also saw their margins narrowing, and physicians were left with more work and less autonomy.

Alternatives
Today, new models of care delivery which complement the move away from FFS are underway across the nation. To ensure that our health care system is sustainable, transformation must occur across all sectors--a coherent strategy for "paying for performance" means we need a provider structure capable of accountability, coordination, and timely, data-driven, self-evaluation.

Some examples of payment models that depart from traditional fee-for-service include:

Shared Savings. The Medicare ACOs program from the Affordable Care Act utilizes a shared savings payment model. Shared savings financially rewards providers who come in under a yearly "benchmark" spending goal and adhere to quality standards.

Episodic or Bundled Payment. Instead of reimbursing per service, bundled payments give providers a lump sum that represents expected costs for a particular episode of care, such as a heart attack. Bundled payments encourage providers to eliminate unnecessary tests and services, while still achieving a good outcome for the patient's health issue.  Read this article for more details. 

Have you heard of other payment models that are reducing patient costs and improving quality of care?   Are you optimistic about the move away from fee-for-service models?

Books Mentioned in The Atlantic article

In class we continued the discussion about patient-centered care, but from the point of the view of the doctor, and cited Meghan O'Rourke's article in The Atlantic, "Doctors Tell All and It's Bad".

Here are the list of books by doctors mentioned in the article, with links to their websites, books, and book reviews.  I recommend reviewing it further, as there are many interesting links, as well as blogs.

• Dr. Atul Gwande, "The Mortal"
• Dr. Terrence Holt, "Internal Medicine" - NY Times Book Review
• Dr. Sandeep Jauhar, "Doctored: The Disillusionment of an American Physician"
• Dr. Danielle Ofri, "What Doctor's Feel"
• Dr. Barron H. Lerner, "The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics"
• Dr. Charles Kenney & Jack Cochran, "The Doctor Crisis" - Amazon link ("Look Inside")
• Dr. Victoria Sweet, "God's Hotel" - "slow medicine", a memoir 

EMR Adoption Model

Understanding the level of EMR capabilities in hospitals is a challenge in the US healthcare IT market today.  Here is an EMR Adoption Model that identifies the levels of EMR capabilities ranging from the initial CDR environment through a paperless EMR environment.

The stages of the model are as follows:

Stage 0: Some clinical automation may be present, but all three of the major ancillary  department systems for laboratory, pharmacy, and radiology are not implemented.

Stage 1: All three of the major ancillary clinical systems are installed (i.e., pharmacy, laboratory, radiology).

Stage 2: Major ancillary clinical systems feed data to a clinical data repository (CDR) that provides physician access for retrieving and reviewing results. The CDR contains a controlled medical vocabulary, and the clinical decision support/rules engine for rudimentary conflict checking. Information from document imaging systems may be linked to the CDR at this stage.

Stage 3: Clinical documentation (e.g. vital signs, flow sheets) is required; nursing notes, care plan charting, and/or the electronic medication administration record (eMAR) system are scored with extra points, and are implemented and integrated with the CDR for at least one service in the hospital.

The first level of clinical decision support is implemented to conduct error checking with order entry (i.e., drug/drug, drug/food, drug/lab conflict checking normally found in the pharmacy). Some level of medical image access from picture archive and communication systems (PACS) is available for access by physicians via the organization s intranet or other secure networks outside of the radiology department confines. 

Stage 4: Computerized Practitioner/Physician Order Entry (CPOE) for use by any clinician is added to the nursing and CDR environment along with the second level of clinical decision support capabilities related to evidence based medicine protocols. If one patient service area has implemented CPOE and completed the previous stages, then this stage has been achieved.

Stage 5: The closed loop medication administration environment is fully implemented in at least one patient care service area. The eMAR and bar coding or other auto identification technology, such as radio frequency identification (RFID), are implemented and integrated with CPOE and pharmacy to maximize point of care patient safety processes for medication administration.

Stage 6: Full physician documentation/charting (structured templates) is implemented for at least one patient care service area. Level three of clinical decision support provides guidance for all clinician activities related to protocols and outcomes in the form of variance and compliance alerts. A full complement of radiology PACS systems provides medical images to physicians via an intranet and displaces all film-based images.

Stage 7: The hospital has a paperless EMR environment. Clinical information can be readily shared via electronic transactions or exchange of electronic records with all entities within a regional health network (i.e., other hospitals, ambulatory clinics, subacute environments, employers, payers and patients). This stage allows the HCO to support the true electronic health record as envisioned in the ideal model.   

Here's a figure that indicates the percentage of hospitals are have achieved the various stages.  Tucson Medical Center (TMC) is a Stage 7 hospital.  Not an easy thing to do!

Sharing Records Called Key to VA Healthcare

In a recent Arizona Republic front-page article (9/2/14), it seems a key reason for the delay in VA healthcare and claims processing is due to the inability for the Department of Defense and the VA to share electronic health records efficiently.

"A July audit by the Defense Department's inspector general found that the Defense Department failed to make proper records transfers to the VA. In the Army, 77 percent of records transferred in 2013 were not timely and 28 percent were not complete."

A key part of the problem is the VA's reliance on old technology. A report released last week by the VA's Office of Inspector General criticized the agency's out-of-date scheduling system. The system has come under fire repeatedly since The Arizona Republic disclosed in April that veterans were dying while awaiting appointments for care.
Read more...

In addition to all the problems plaguing the VA, old technology and an inability to transfer records from the DoD adds to the inefficiencies and time delays among VA patients. The Defense Department plans to buy a new system, while the VA intends to modernize its own in-house design.  But modernization still takes time.

Any ideas about what the VA should do?  Are they even capable of doing it in-house?

Where to find good health-related articles?

One of the best places to look for recent healthcare news, or topics in the news are Healthcare blogs.  On the right side of this blog is my BLOG LIST of a few good ones, but I'm sure there are more.

Please comment below on this blog or on our Facebook Group for other good sources you've found (that didn't involve an extensive Google search).  After all Google searches only account for like 20% of the web.

That is, unless you know how to be a more sophisticated user of Google search.  Go to http://www.avatargeneration.com/2012/11/tips-for-students-doing-online-research/ for details.

How Many Die from Medical Mistakes?

"How Many Die From Medical Mistakes," watch this video to give you a more detailed context of the problem:

“Your Hospital May Be Hazardous To Your Health,” co-published with PBS Frontline as part of a five-day hackathon that brought together teams of journalists, filmmakers, developers and designers to produce interactive stories for the Web.

The piece draws from ongoing reporting about patient safety by ProPublica reporters Marshall Allen and Olga Pierce. "Our collaborators were documentary filmmakers Tom Jennings and Sabrina Shankman and Director of Development Sam Bailey, all with Frontline, and a team from Ocupop, a web design and development group based in Milwaukee, Wisconsin."

Comments?

Why American Health Care is So Pricey

Americans pay more for health care than people in many other developed countries, and Elisabeth Rosenthal is trying to find out why. The New York Times correspondent is spending a year investigating the high cost of health care. The first article in her series, "Paying Till It Hurts," examined what the high cost of colonoscopies reveals about our health care system; the second explained why the American way of birth is the costliest in the world; and the third, published this week in The Times, told the story of one man who found it cheaper to fly to Belgium and have his hip replaced there, than to have the surgery performed in the U.S.

To hear the Fresh Air interview with Elisabeth Rosenthal, to go http://www.npr.org/2013/08/07/209585018/paying-till-it-hurts-why-american-health-care-is-so-pricey

Hospital Charges in US Vary Wildly

As discussed in the Time article on "The Bitter Pill", the government is publicly revealing how much hospitals charge, and the differences are astounding: Some bill tens of thousands of dollars more than others for the same treatment, even within the same city.

 For example, the average charges for joint replacement range from about $5,300 at an Ada, Okla., hospital to $223,000 in Monterey Park, Calif., the Department of Health and Human Services said. That doesn't include doctors' fees.

 "It doesn't make sense," Jonathan Blum, Medicare deputy administrator, said Wednesday. The higher charges don't reflect better care, he said. Blum said the Obama administration hopes that releasing the information, at www.cms.gov online, will help lead to answers to the riddle of hospital pricing - and pressure some hospitals to lower their charges.

 The database also will help consumers shop around, he said. "Hospitals that charge two or three times the going rate will rightfully face scrutiny," Health and Human Services Secretary Kathleen Sebelius told reporters. Moreover, consumers will get insight into a mystifying system that too often leaves them with little way of knowing what a hospital will charge or what their insurance companies are paying for treatments, Sebelius said.

Here are hospital charges in Tucson:

Read on...

A usability issue: Medical devices constantly beeping

I found this article in the AZ Daily Star on an AP report about delays in treatment due to medical devices constantly beeping.   The article goes on to say that hospital workers are "desensitized" to the beeping and so ignore the noise, leading to "at least two dozen deaths a year on average," a hospital accrediting group reported.  Like alert fatigue, where clinicians ignore alerts because they get so many of them that they override them (a simple workaround).   The beeping devices include those that measure blood pressure and heart rate, among other things. Some beep when there's an emergency, and some beep when they're not working. That can lead to noise fatigue and the delay in treating a patient can endanger lives, the accreditation commission says.

Read on...

TQM and Physician Involvement

In the case we read about Virgina Mason's use of Toyota's Production System (TPS) and the associated management philosophy of Total Quality Management, which was adopted widely among health care delivery organizations in the early to mid 1990s (p. 5 in case).  Experience with these techniques was mixed, with some observers arguing that TQM was not applied correctly in health care and others arguing that the approach was ill suited to an industry in which the underlying science was based on biology not physics, cause and effect relationships were poorly understood and the primary worker (the doctor) was only loosely affiliated with the organization.

In a 2003 survey by Casalino and colleagues found that even after more than a decade of focus on process improvement, physician groups’ use of the of tools for process management, such as clinical practice guidelines, disease registries, and performance measurement and benchmarking was limited.

One important factor in whether or not TQM gained traction in a health care delivery organization and was effective was physicians’ involvement in hospital governance. The alignment between physicians and the health care delivery organization (defined as “the degree to which physicians and organized delivery systems share the same mission and vision, goals and objectives, and strategies, and work toward their accomplishment”) was an important determinant of whether physicians adopted a range of clinical management practices aimed at improving clinical performance.

We will next read how Intermountain Healthcare changed clinical operations.  As an example of how Intermountain uses lean management strategies, here is a video that gives you an idea of how early attempts at TQM can work today.

L. Casalino, R.R. Gillies, S.M. Shortell et al.,“External Incentives, Information Technology, and Organized Processes to Improve Health Care Quality for Patients With Chronic Diseases,” JAMA (2003), 289, 434-441.

The Direct Project: Exchanging Health Information Over the Cloud

I found this site at IBM Developer about the Direct Project.  This is a cloud-based, open source, Java-based client that allows secure email to be sent in health IT systems.   The articles starts by stating,

"Cloud computing has been a game-changer in promoting system interoperability and reducing IT costs in almost every other industry, but it has been difficult to adopt the cloud computing paradigm for health IT. Today, health IT in the cloud is mostly limited to hosted electronic health record (EHR) providers for small practices such as eClinicalWorks and PracticeFusion (see Resources)   Such providers focus on hosting data and services (in the software-as-a-service or SaaS model), but not on data exchange. Large hospital systems have so far not adopted cloud computing in any meaningful way."

The article provides great technical and practical information about the history of Direct, how it works, and the challenges it faces.  There are also links to other resources.

New ACO expands in Tucson

In today's Arizona Daily Star, the headline reads, "New 'accountable' model of health care expands here."  I mentioned in class that TMC had an ACO, called Arizona Connected Care.  The CIO is a UA Masters in MIS alum, Michael Griffis.  You can check him out on LinkedIn. (Maybe there's a project there for some of you.)

Arizona Connected Care, is what's known as an "accountable care organization."  It is the only accountable care organization in Southern Arizona, and it's the first markets where UnitedHealthcare is partnering with an ACO.

At least three accountable care organizations are operating in Arizona. Patients do not need to do anything to participate. As long as their care providers are part of Arizona Connected Care, they will see no changes other than more follow-up and attention from providers in the organization.

The article goes on to say that thousands of Southern Arizonans enrolled in UnitedHealthcare "will soon be able to get care through a unique local business that's intended to contain spiraling medical costs by giving patients more attention."  The goal is fewer chronically ill patients and fewer hospital readmissions.

"Monitoring patients after they are discharged can help keep them from falling through the cracks and improve communication between various providers like a hospital, nursing home, physical therapist and rehab center," officials say.

Read more from the article, and check out Arizona Connected Care.

Growing Pains as Doctors' Offices Adopt Electronic Records

Information technology has transformed much of the American economy, but its use in health care still lags, especially when it comes to electronic medical records.  Here's an example: The state of Colorado runs a computerized registry where any provider who gives a child a vaccine can report that information. The system should help kids stay current with their immunizations.

But the state's computer system isn't compatible with most of the ones doctors use, so many practices don't update the central database because it's just too much extra data entry, says Dr. Allison Kempe, director of the Children's Outcomes Research Program at the University of Colorado School of Medicine. That means doctors and researchers like her, who try to keep kids' immunizations on track, can't rely on it to make sure a vaccine isn't missed or given twice.

We're talking thousands of data fields around things that are life and death," says Farzad Mostashari, the national coordinator for health information technology at the Department of Health and Human Services. His office is charged with leading American medicine's digital transformation.  Patients would get better care, at lower cost, if health care systems could share patient records easily. But that won't happen until doctors and hospitals start getting paid for being smart about IT. 

Read more, or listen to the story.... and follow links to Kaiser Health News at the end of the article for other excellent news on health and healthcare.

When Doctors Don't Listen

I was driving to school and wished I could share this with you in the moment.    It was on the Diane Rheem show, and she was interviewing two doctors about a book they just wrote, "When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests."

The United States spends $2.5 trillion on health care, accounting for more than 16 percent of our gross domestic product. But more spending has not translated into better results: the U.S. consistently ranks below other countries on delivering quality health care. A major culprit in rising costs is medical testing, which totals $250 billion extra every year. In a new book, two Harvard doctors say physicians rely too much on algorithms and formulas to make a diagnosis, leading them to order unnecessary tests. How to get the right diagnosis and better care from your doctor.

The focus of the book is on 8 pillars that patients can do to get the care they need.  

Here is the Diane Rhem show about this topic.  Here is the transcripts, or you can listen to the audio. If nothing else, read the excerpt from the book, as well as the comments from others.  

Add your own thoughts to this post.    Have you are a loved one or friend experienced doctor visits where tests are done before they truly understand what is wrong with the patient?  Do you think the 8 pillars will work?  Why or why not?

UA@WORK

  Maybe you've seen this "Smart Moves" icon around campus.  The U of A is helping employees and students be able to identify programs, services activities and food choices that promote a healthy lifestyle.  David Salafsky, director of health promotion and preventive services for the Campus Health Service. "We have a great campus community that promotes walking, biking and a range of physical activities. A lot of programs are already in place. This is really about identifying them."

I've asked David to come to talk to our class.  Follow other UA@Work initiatives.

Would you be more likely to use services that had the "Smart Moves" icon?  Why or why not?