Tuesday, July 26, 2011

Will Adoption of EMRs Cause Hospital Error Rates to Soar?

Voluntary human reporting of errors will be replaced by 'Global Trigger' tools

Its nearly impossible to receive meaningful information from hospitals or physicians about the quality of their work. The information that is available is from data that is tabulated from voluntary contribution of mistakes. I am not sure we need advanced degrees in psychology to understand that it is entirely against human nature to call out our own mistakes, and the mistakes of others...especially when a multi-million dollar lawsuit or loss of ones livelihood may be the result.

So, it may not come as a surprise, that despite more than a decade of national focus on patient safety, medical errors and other adverse events occur in one-third of hospital admissions—as much as ten times more than some previous estimates have indicated, according to authors of a new study in the April issue of Health Affairs .

The patient safety study, conducted by David Classen of the University of Utah and coauthors at the Institute for Healthcare Improvement, compared three methods for detecting adverse events in hospitalized patients, including the Institute’s own Global Trigger Tool. The study drew on comparable samples of patients from three leading hospitals that had undertaken quality and safety improvement efforts.

Among the 795 patient records reviewed, voluntary reporting detected four events, the Agency for Healthcare Research and Quality (AHRQ) Indicators detected 35, and the Global Trigger Tool detected 354 events, ten times more than the AHRQ method. In other words, the AHRQ indicators and voluntary reporting missed more than 90 percent of adverse events identified by the Global Trigger Tool. If anything, the researchers say, their findings are conservative, because they rely on medical record review, which would not detect as many adverse events as direct, real-time observation would.

The researchers say that reliance on voluntary hospital reporting or the AHRQ indicators could lead to seriously flawed perceptions of patient safety in the United States. They also note that the Global Trigger Tool detected a much higher rate of adverse events for hospitalized patients than previous studies have shown. Although the Global Trigger Tool is a somewhat more resource-intensive method because it involves medical record review, the researchers suggest that it could be incorporated into commercial electronic health record systems, thus making it easier and less costly to use.

I believe that we will see the rate of adverse events begin to increase as we approach the end of the $44,000 per physician EMR federal stimulus payments, and the graduated introduction of Medicare EMR milestones thru 2015.

As the reported US medical error rate begins to approach the reality of medical practice, it will be interesting to see how risk managers view the comparison of local care versus a global healthcare option, when the true medical outcomes are compared.

Could the statistics eventually show that it is a greater medical risk for an employer to send patients to the local hospital with questionable outcomes, vs the super specialty hospital in Bangalore that delivers extraordinary medical outcomes and patient satisfaction?

Sunday, July 24, 2011

Deloitte Study Challenges Medical Tourism's Basic Assumptions


Medical Outcomes and the Patient Healing Experience Trump Tourism

Given the anecdotal reports of a decreasing flow of medical travelers from the US to other countries, I sometimes wonder if our nascent industry has facilitated all the hips and knees that were primed and ready to go...and have now gone. I still get excited calls about the 60 Minutes segment featuring the hip surgery, waving palms of Chennai and boat drinks. Of course, these are now reruns from the original several years ago. The first movers in this industry now have about five years of experience...and patient outcomes data.

The well written Deloitte US Consumer Survey 2011 highlights what IndUShealth has observed for several years...that the travel piece of Medical Tourism is last on the list of priorities for the medical traveler. This is especially true for corporate programs.

The next generation of 'post 60 Minutes Medical Tourists' will be far more discriminating in their expectations for providers to prove a claimed level of quality. The Deloitte report also highlights the lack of confidence the healthcare consumer has for the traditional sources of healthcare quality data. This gives the next generation of facilitator the opportunity to use medical outcomes and patient satisfaction data for competitive advantage.

This is where the strategy of having scores of hospitals and physicians all over the planet to choose from breaks down. Nice physician bios that have been cut and paste from hospitals to facilitators..and then to other facilitators, is just not going to suffice. The consumers will be demanding outcomes data over a period of several years.

Is it more compelling to see two or three surgeons having great outcomes on thirty patients in two hospitals...or thirty surgeons doing two surgeries in 20 different hospitals? The market will certainly decide.

And the data that is provided for the consumer should be not just promotional from the hospital...to be believable, it should be representative of those patients the facilitator has actually managed.

These key metrics should provide enough data for a patient to abandon the painful familiarity of the US system, and embark on a healing journey that is in some cases on the far side of the world.

So what are some these key metrics?
  1. Medical outcome followed over a period of at least a year
  2. Post surgical infection rate
  3. Patient satisfaction for the physician, hospital and facilitator
  4. Cost
While it is now nearly impossible to get this information from a US hospital, savvy CEOs will begin to use the outcomes data from their star physicians to differentiate themselves in the market place. Documenting the positive patient experience will take on renewed importance, and in some markets, the only differentiating factor between an exceptional local hospital and a Bangalore super specialty hospital may only be the cost of the procedure.

Facilitators that hope to survive on internet generated patient referrals, with few care management capabilities, may soon face the same fate as travel agents did with the emergence of ubiquitous online aggregators like Expedia, and direct availability of tickets from Southwest and American.

Monday, July 11, 2011

How is it Possible to Travel Further Yet Heal Faster?

The surgeons experience, uninterrupted healing and generous professional staffing ratios are the key to India's quick surgical recoveries.

The surgical experience of a two patients, one in the US and one in India, is nearly identical. Experienced surgical team, state of the art instruments and identical orthopedic implants.

Day of Surgery

The day of hip replacement surgery is mostly a day to recover from the procedures. But it is not
just about rest. Depending on the time of day of surgery, the patient may be asked to sit in a chair or on the side of the bed.

Patients in India and in the US will begin simple activities including ankle pumps, leg lifts and heel slides. Both nursing staffs will make sure that the patients take sufficient pain medication to allow them to participate in their rehabilitation exercises.

Hospitalization

During hospitalization, the patient will meet with the physical and occupational therapists. The physical therapist will work on mobility, strengthening, and walking. The occupational therapist will work on preparing for tasks such as washing, dressing, and other daily activities.

Therapy progresses at a different pace for each patient in India and the US. Factors that will affect the rate of the patient's progression include strength before surgery, body weight, and ability to manage painful symptoms. The type and extent of surgery can also affect the patient's ability to participate in physical therapy.

Discharge/Rehabilitation

In the US, the patient will be discharged from the hospital in
3-5 days. In India, the patient will be discharged in 14-17 days. This is the point of healing divergence between the two healthcare systems. For reasons outlined previously in this blog, there is no way for a US hospital to indulge a patient in 14 days of therapy. So while the Indian patient is working daily on mobility, strengthening and walking...the US patient is making plans to return home, set up appointments for rehabilitation in another location and trying arrange for transportation.

Post-surgical rehabilitation hurts. It is a rare patient that is able to muster the fortitude needed to maintain a rigorous schedule of physical therapy, and self-manage pain medication. So, the US patient, due to both human nature and sporadic exposure to healing professionals, begins to slow down on his journey to recovery, when compared to his Indian counterpart.

Complications can arise

After hip replacement surgery, patients must restrict certain activities to prevent problems with the hip replacement implant. The concern is that hip replacement implants are not as stable as a normal hip joint. This means that it is possible for the ball of the ball-and-socket hip replacement to dislocate.

The Indian patient has had 17 days of practice in learning the limitations of their new hip replacement...their US counterpart only received a few instructions after surgery.

What are some of the life-long practices that a patient will need to 'unlearn?'
  • Crossing the legs
    Patients should not cross their legs after hip replacement surgery. When putting on socks and shoes,they should not cross their legs to bring the foot towards the body. The therapist will instruct the patient on how to safely get dressed. The patient should not sleep on their side until instructed by the surgeon. Some surgeons may have patients sleep with a pillow between their legs to prevent them from crossing.

  • Forward bending
    It is important not to bend a hip up more than 90 degrees. In general, if the knee is below the hip joint, you are in a safe position. Problems occur with deep cushioned seats or low seats (such as toilets).
It is important to work with the physical therapist and occupational therapist to learn the proper ways to get dressed, sit down, walk, and perform other routine activities.

Why is it so important that these limitations be learned?

As mentioned above, a hip replacement implant is not as stable as a normal hip joint. If a dislocation of the hip replacement occurs, the hip implant must be put back in place. This can usually be done in the emergency room, but may require additional surgery. Furthermore, hip replacement dislocations can damage the implant and decrease the chances of success after hip replacement surgery.

So, after 17 days, the Indian patient has had continuous therapy, no distractions, continuous practice with the new limitations of the implant, and is now far ahead of their US counterpart on their healing journey.