Famed Palo Alto industrial design firm IDEO is taking on the challenge of designing a more-patient friendly hospital process. Many of the ideas they are talking about are similar to the quality circles that the Japanese used to successfully destroy threaten the US auto industry. Don Berwick has been promoting these ideas in health care for many years, as I posted about here.

The most interesting idea the IDEO team comes up with is rapid prototyping.  They changed many things about the process, did it very quickly, and then observed the results immediately.

Ordinarily the hospital spends a year or two in committee, create what they think is the perfect team process, and then goes out and tries it and fails. At IDEO we say, "fail early to succeed sooner." So after a half hour bringing into the field, we see how colleagues use it. Then we come back and revise it. So we get rapid prototyping in place. Previously it was death by committee.

On a side note, IDEO made its name in part on its design of the Palm V PDA (on the left in the picture).  What’s not so widely known is that IDEO stole assumed its role in the design process from a smaller design firm (for reasons that were totally unrelated to the design work). The smaller firm had already come up with this design, which IDEO if anything made less attractive in the final product. So it just shows that even the best and brightest amongst us have skeletons in our closets.

California Blue Cross (Wellpoint) is one of the plans participating in the California wide Pay for Performance (P4P) scheme, which rewards physician groups for improving a variety of quality scores.  The scheme is administered by the IHA, a provider/payer talking shop that’s seized on quality as an issue that might help improve the antagonistic relationship between plans and providers. This article from MD Practice Alert describes the way Blue Cross HMO is using pay for performance. The article is a little confusing; despite what it says there is no monolithic P4P standards.  All the health plans involved have slightly different metrics. The key thing is that they are all paying bonuses based on some performance measure and making those measures and bonuses publicly available.  For more information on differences between the plans, see here.

Like the other plans Blue Cross is rewarding the groups on the more preventative HEDIS-type measures that are the core of the current P4P. However, one difference between Blue Cross and some of the others is that it’s rewarding physician groups that have utilization management systems that track care given to the group’s patients outside the group’s walls, and especially that given to long-term inpatients in hospitals, rehab centers and skilled nursing facilities. In addition, Blue Cross is paying out more money ($28m) and a higher percentage of its overall payment budget (10%) via its version of P4P.

At the tail end of last week the RWJ-funded Health-e-technologies Initiative organization gave out its first round of grants.  Many of the subjects looked familiar to those of us who’ve spent time in the (nominally) for-profit eHealth sector.  For instance, Kate Lorig at Stanford who’s already running a huge study on self-treatment among arthritis patients will do a clinical trial by randomizing a sub-set of diabetics into either a web-based set of self-management classes or a control group.  Barbara Rimer at UNC is studying the effectiveness of cancer lit-servs.

Back in the mid-1990s several people were looking at these kinds of interventions having heard good things anecdotally about their effectiveness. For example, back in 1996 I had a cancer patient who was active online come and talk to my health care IT client group to show them what was happening in the on-line patient community. There is also lots of anecdotal evidence from work being done with online self-management programs, and even some real studies. So in some ways these studies are old news.  However, theoretically a health care product or service’s introduction  should go in the order A) Initial use and pilots, B) Clinical study (if possible RCT) C) Market development and adoption.

In the case of these  IT-based self-treatment technologies, by 1997-8 the eHealth market fever had taken over and soon there was a software package and web site for every condition. No one did any clinical trials to see what worked (mind you that’s equally true for most new surgical procedures).  Now it looks like the clinical trials are going to get done.  Presuming that they show that eHealth self-care works, hopefully the lack of funding from Medicare and private insurers that delayed the emergence of eHealth in practice (rather than its emergence on the stock market in the bubble years) will be resolved. (Some companies like Lifemasters and American Healthways have been growing recently, but it’s been a decade of tough sledding, and most of their business is call center-based). After all, if web-based self-care makes patients better and saves money, it’ll be that much harder to deny it a CPT code.

Meanwhile, the Health-e-initiative has launched a discussion-based web site. It’s worth taking a look, and you can post if you like (not that I’ve got round to doing that yet).

AHRQ, the Agency for Healthcare Research and Quality has put out another study on medical errors This one has a slightly different methodology than the IOM’s 1999 "To Err is Human" study. The researchers estimated that the study’s findings mean about 32,600 deaths result from various specifically defined medically-caused injuries in the U.S. each year.

The IOM’s estimates are of 44,000 to 98,000 deaths.  Some of the difference is due to the AHRQ’s methodology and choice of data set. (Here’s the abstract).  Their data set was much larger than those used by the IOM, and was based on administrative and billing data but didn’t include chart review.  The IOM study was based mostly on various other studies that included chart review.  In addition the new data focuses on "injuries" resulting from specific procedures and as far as I can tell doesn’t include adverse drug reactions, so the actual number of total deaths is likely to be much higher.

It’s also worth noticing that the attempts to find the truth in what’s really going on are hampered by the age of the data, and the type of data collected. But the direction in which all the data points is very clear. It’s dangerous in that big white building, and going into hospital can be very hazardous for your health.  Thankfully, from all anecdotal evidence I’m hearing about/seeing, providers are getting the message and are working on getting the CPOE systems, drug databases and workflow systems into the hands of clinicians.  Hopefully, this will mean that those error or "injury" rates will start coming down.

On a childish aside, if you check out AHRQ’s URL you’ll notice it used to be called the The Agency for Health Policy and Research. Think about that for a moment.  Shouldn’t research come before policy, you say?  Well they were going to name it that way until someone noticed it’s acronym would be AH-CRaP).

A cardiologist wrote to me about my post concerning the nurses fired for administering drugs without physician approval. The response suggests that there should have been standing orders, which sounds logical to me:

In regards to intubated patients, 1) almost all ventilated patients have standing orders for either Diprivan, Versed, or Ativan; 2) these sedating medications are held prior to extubating patients; 3) in my experience, (for what it’s worth), patients who extubate themselves usually stay off the vent, either because they were ready to be extubated, or because they would rather die than be re-intubated. I don’t know why those nurses were disciplined. If they willfully ignored the MD’s order, they should be fired (unless the MD was grossly incompetent). If said MD did not given standing orders for Diprivan, etc, s/he deserves to be paged throughout the night.  . . . One other possibility:  the physicians were so incompetent, the nurses took it upon themselves to initiate sedation orders. But again, if standing orders were present, this would not be a violation..

I am deeply puzzled by this one.  Apparently patients on respirators sometimes try to pull their tubes out of their throats in a panic, and administering such patients Diprivan immediately calms them and potentially saves their lives. A hospital in Louisville, Kentucky has  fired 14 nurses for giving the sedative to patients on respirators without a doctor’s order.  Now I am not an expert on clinical procedures so take everything I say as opinions held very gently, but…..

a) Wouldn’t there or shouldn’t there typically be a standing order from the doctor as to what a nurse should do if a patient starts trying to pull their respirator out?
b) If (at least) 14 nurses were routinely doing this, it is definitely a system problem.  Should not the hospital have been educating the nurses about the rules before they fired them, as they apparently are doing now for those not fired? Has anyone in the hospital management been fired for allowing so much to go wrong on their watch?
c) Is it realistic for nurses to know these rules? On Saturday I watched a baseball play-off game where a hitter being paid over $4 million a year failed to score the winning run because he mis-interpreted a rule.  Yet he’s in the game I’m watching as I type this on Monday night!
d) A nurses’ association is trying to unionize this hospital.  Were those nurses fired purely for the sedative offence or were they involved in union activities?
e) Who creates the Kentucky Board of Nursing standards? Am I suspicious, or might a core of doctors be involved here. Don’t forget that several states restrict midwives from delivering babies, and even prosecute them, when in most other countries they are a core part of the labor and delivery system*, and there is very credible evidence that using midwives for routine births is safer than using OBGYNs.  Those rules came from the political power of organized medicine. Is something similar going on here regarding the ability of nurses to encroach on anesthetists turf?

I don’t know the answers to this issue.  But this mass firing looks like a symptom of a wider disease at this and probably other hospitals.  If you have comments, please email me and I’ll follow up later.

*For example, while the United States has 35,000 obstetricians and about 5,000 midwives, Great Britain has 32,000 midwives and fewer than 1,000 consultant obstetricians.

While the managed care industry generally has more or less given up the concept of trying to manage the way physicians practice, it’s not quite so in California. The CCHRI, a mostly payer/provider funded group, albeit with representation from organized medicine, reported late last week that both clinical performance indicators and member satisfaction are getting better.

How come the connection between managed care and quality is still alive in California, after a combination of physician and consumer outrage beat managed care to death with a stick in the rest of the USA? Well, like everything else it’s mostly an accident of history.  California has big medical groups.  They tend to have the management structures in place that allow them (even if they haven’t always) to both measure their physicians’ clinical performance and work to actively change their behavior.  Outside the left coast physicians still tend to practice in smaller groups and the groups that do exist tend to be smaller, looser or affiliated with a clinical teaching practice (and therefore be unmanageable!).

So how did California get that way?  Well, by dint of historical accident, it had the Kaiser Permanente organization. Because of the inherent price advantage Kaiser’s pre-paid (or capitated) plan had over the traditional insurance companies, in the late 1970s and early 1980s Blue Cross went actively looking for physician organizations that looked something like the Permanente Group on which to base their incipient HMO, the forerunner of HealthNet.  They found several groups mostly in southern California.  Of course they were historical accidents too.  One, Friendly Hills, was a group of family docs who’d covered for each other on call and gradually developed closer business links.  Another, Mullikin, was (I was once told) a haven for gay doctors who couldn’t find other places to practice. By the mid-1990s these groups and their ability to deliver high quality population-based care in a heavily internally-managed environment was well known in the industry. I spent many a session frightening East Coast hospital management teams with the specter of what would happen to their  occupancy rates if those crazy Californians brought their "bed-days per thousand" rates to their town. It even got the attention of the east coast medical intelligensia. Unfortunately both the greed aggressive business tactics of the health plans and the greed incompetence of the Medpartners organization which bought the vast majority of these groups had driven them into chaos and bankruptcy by the late 1990s.

It appears that the medical groups are recovering from that era of chaos and are now getting back onto the "good" managed care track.  With employers paying more and health plans not being under the financial gun they were in the mid-1990s, the CCHRI report shows that there’s potential within California for real improvement in those population clinical improvement measures that we were all talking about 10 years ago.