Facebook is releasing an EMR? Jim Cramer is going to work at Epic? April Fools! On today’s actual Health in 2 Point 00 Episode 76, Jess asks me about the follow up from Health Datapalooza, which ended with the government saying they will be changing the world and that everyone should join them in their initiative to innovate digital health. AHRQ & CMMI ran digital health challenges, and CMMI will be doing an AI challenge for $1 million for startups in the space. Speaking of the government, Seema Verma was in the news for her PR spending and as I said “Evil Twin Seema” and “Good Seema” are joined at the hip and they should “not screw around on the PR front”. In other news, MountSinai launched a digital health institute to develop advances in artificial intelligence and other emerging health care technologies spaces. Clover Health laid off a ton of people, and according to me, they are starting to get serious because running a Medicare Advantage plan is hard work — Matthew Holt
E-Prescribing: Experiences from Physician Practices and Pharmacies
The May 2012 edition of the Journal of the American Medical Informatics Association (JAMIA) offers the opportunity for a second look at an important recent study on e-prescribing. The study, “Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies,” examines practitioners’ experiences with this potentially game-changing technology.
The study, first available on the AMIA web site in November 2011, is now one of 12 articles included in the JAMIA issue on the “Focus on health information technology, electronic health records and their financial impact.” (It is available at no cost at http://jamia.bmj.com/content/current.) In the article, Joy M. Grossman, PhD, and colleagues from the Center for Studying Health System Change (HSC) conducted a qualitative analysis of 114 telephone interviews with representatives from 97 organizations including 24 physician practices, 48 community pharmacies, and three mail-order pharmacies actively transmitting or receiving e-prescriptions. This study is part of a larger qualitative project on e-prescribing. An earlier publication, released in May 2011, explored physician practice use of e-prescribing to access external information on patient medication histories, formularies and generic alternatives. It can be found at http://www.hschange.org/CONTENT/1202/.
Sorry. Health Care Reform Can’t Wait for Quality Measures to Be Perfect
There’s a debate in the United States about whether the current measures of health care quality are adequate to support the movement away from fee-for-service toward value-based payment. Some providers advocate slowing or even halting payment reform efforts because they don’t believe that quality can be adequately measured to determine fair payment. Employers and other purchasers, however, strongly support the currently available quality measures used in payment reform efforts to reward higher-performing providers. So far, the Trump administration has not weighed in.
The four of us, leaders of organizations that represent large employers and other purchasers of health care, reject any delay in payment reform efforts for the following three reasons:
Even imperfect measurement and transparency accelerate quality improvement. One set of measures often questioned is the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs) used by the Centers for Medicare and Medicaid Services (CMS) and others in value-based payment programs. These indicators measure surgical complications and errors in hospitals, which is critical given that one in four hospital admissions is estimated to result in an adverse event.
PSIs remain among the most evidence-based, well-tested, and validated quality measures available. CMS uses many in its value-based purchasing programs. Use and reporting of PSIs through AHRQ’s Medicare Patient Safety Monitoring System has measurably improved quality. For instance, CMS reported a reduction in inpatient venous thromboembolisms (VTEs) from 28,000 in 2010 to 16,000 in 2014, meaning that 12,000 fewer patients had potentially fatal blood clots in 2014.
In addition to using quality measures in payment programs and for quality improvement, making measures public is key to accelerating change. “If transparency were a medication, it would be a blockbuster,” concluded a multi-stakeholder roundtable convened by the National Patient Safety Foundation’s Lucian Leape Institute in 2015. The foundation’s report cited the Leapfrog Group’s first-ever reporting of early elective delivery rates by hospitals in 2010, which galvanized a cascade of efforts to curtail the problem and thus reduce maternal harms and neonatal intensive care unit (NICU) admissions. This was effective: The national mean of early elective deliveries declined from a rate of 17% to 2.8% in only five years.
Safe Doctors, Unsafe Patients: A Tale of Two Infections
Call it a tale of two infections. It’s the story of how hospitals have blocked transmission of a dangerous infection that patients can give doctors, while a hospital-caused infection that can kill patients continues to be widely tolerated. It involves saved lives and endangered ones – and also of billions of dollars spent needlessly due to unsafe care.
The infection that’s been conquered is occupational transmission to doctors and other health care workers of HIV, the virus that causes AIDS. When AIDS first burst on the scene in the early 1980s, it was “disfiguring, debilitating, stigmatizing and inevitably fatal,” in the words of Dr. Paul Volberding, a treatment pioneer. With the disease’s spread poorly understood, “the fear of contagion [was] hanging over our heads,” Volberding recalled.
However, once the mode of transmission was identified– exposure to HIV-infected blood or other bodily fluids – precautions were rapidly put into place. From 1985 through 2013, there were just 58 confirmed cases of occupationally acquired HIV infection reported to the Centers for Disease Control and Prevention (CDC), according to a Jan. 9 CDC report. Since 1999, there’s been only one confirmed case of occupational transmission, involving a lab tech infected via a needle puncture in 2008.
Reported occupational infection “has become rare,” the CDC concluded, likely due to prevention strategies and “improved technologies and training.”Continue reading…
Health Data Outside the Doctor’s Office
Health primarily happens outside the doctor’s office—playing out in the arenas where we live, learn, work and play. In fact, a minority of our overall health is the result of the health care we receive. If we’re to have an accurate picture of health, we need more than what is currently captured in the electronic health record.
That’s why the U.S. Department of Health and Human Services (HHS) asked the distinguished JASON group to bring its considerable analytical power to bear on this problem: how to create a health information system that focuses on the health of individuals, not just the care they receive. JASON is an independent group of scientists and academics that has been advising the Federal government on matters of science and technology for over 50 years.
Why is it important to pursue this ambitious goal? There has been an explosion of data that could help with all kinds of decisions about health. Right now, though, we do not have the capability to capture and share that data with those who make decisions that impact health—including individuals, health care providers and communities.
The new report, called Data for Individual Health, builds upon the 2013 JASON report, A Robust Health Data Infrastructure. It lays out recommendations for an infrastructure that could not only achieve interoperability among electronic health records (EHRs), but could also integrate data from all walks of life—including data from personal health devices, patient collaborative networks, social media, environmental and demographic data and genomic and other “omics” data.
The Dangers Of Quality Improvement Overload
Quality improvement (QI) and patient safety initiatives are created with the laudable goal of saving lives and reducing “preventable harms” to patients.
As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.
We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.
National Quality Improvement Initiatives
Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals.
We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others.
To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change: “You cannot go from imperfect to perfect. It’s a slow process.”
While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change.
Frontline providers often bristle at expectations from those they believe have little understanding of the demands of their daily work.
In a Quiet Move, Washington Replaces the Head of AHRQ. Is It Too Late to Save the Agency?
Stealthily, AHRQ has acquired a new head, but the ax still hovers over it.
Very quietly, researcher Richard Kronick, PhD was named by the Department of Health and Human Services (HHS) to be the new director of the Agency for Healthcare Research and Quality (AHRQ). He joins an organization that remains squarely on the House GOP’s chopping block and with few friends strong enough to ward off the blow.
Last fall, when a House appropriations subcommittee voted to eliminate all AHRQ funding, I wrote that the agency’s execution went almost unnoticed: it didn’t even rate a separate mention in the committee’s lengthy press release.
Back then, the House GOP’s big target was Big Bird, a/k/a funding for public broadcasting. Since then, the rampaging Republican right-wing has decided it won’t approve subsidies to farmers unless it can also slash food stamps to the poor and that undocumented immigrants are mostly a law-and-order problem, not a human one. That these positions contradict views held by many conservative Republican senators, governors and party leaders has had little to no effect.
Enter Kronick, after a months-long search to replace Dr. Carolyn Clancy, who’d held the top AHRQ post since February, 2003. Oddly, the announcement by HHS Secretary Kathleen Sebelius wasn’t posted on the HHS website or even the AHRQ one. Searching Kronick’s name simply turned up press releases from his current position as deputy assistant secretary for health policy. According to MedPage Today, the naming of Kronick was made “in the department’s daily electronic afternoon newsletter.”
Why? My guess: politics.
Clancy was known for good relations with policymakers of both parties; she was upgraded from “acting director” to permanent status during the George W. Bush administration. Her predecessor, Dr. John Eisenberg, enjoyed a similar bipartisan rapport. Of course, that was before conservatism gave way to crusaders. Kronick, by contrast, has a background almost tailor-made to tick off Tea Partyers.
6. Invest in the basic science of measurement development and applications.
The unfortunate reality is that there is no body of expertise with responsibility for addressing the science of performance measurement. The National Quality Forum (NQF) comes closest, and while it addresses some scientific issues when deciding whether to endorse a proposed measure, NQF is not mandated to explore broader issues to advance the science of measure development, nor does it have the financial support or structure to do so.
An infrastructure is needed to gain national consensus on: what to measure, how to define the measures, how to collect the data and survey for events, what is the accuracy of EHRs as a source of performance, the cost-effectiveness of various measures, how to reduce the costs of data collection, how to define thresholds for measures regarding their accuracy, and how to prioritize the measures collected (informed by the relative value of the information collected and the costs of data collection).
Despite this broad research agenda, there is little research funding to advance the basic science of performance measurement. Given the anticipated broad use of measures throughout the health system, funding can be a public/private partnership modeled after the Patient-Centered Outcomes Research Institute or a federally-funded initiative, perhaps centered at AHRQ. Given budgetary constraints, finding the funding to support the science of measurement will be a challenge. Yet, the costs of misapplication of measures and incorrect judgments about performance are substantial.
A Roadmap For Patient Safety and Quality Improvement
This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.
An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.
A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.
Today, based on years of work by patient safety researchers—including many at Johns Hopkins—hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.
Community Care of North Carolina’s Last Chance: To Fool the Legislature Rather than Answer the Questions
It’s not quite time to publish the obituary for by far the most extensive patient-centered medical home (PCMH) network in the country, Community Care of North Carolina (CCNC) but it’s certainly time to spellcheck it. The HMO-friendly GOP controls the statehouse, a blistering audit on Medicaid management has just been released (with plans for a CCNC-specific audit in the works), and the state’s most influential media outlet has ”vindicated” those who were excoriated for daring to question it, such as me, to name one random person who has frankly obsessed with it. (This might explain why I never get invited to parties.)
By way of background, the state’s Medicaid agency initiated what might loosely have been termed an enhanced-access model almost 15 years ago, and have subsequently expanded their experiment into a full-fledged patient-centered medical home, which currently covers many disabled members, the large majority of the non-disabled adults, and most of the children.
This wasn’t just any old medical home – it was the “poster child” for the PCMH movement, even making it onto NPR. Here is the influential and literate Disease Management Care Blog on the subject:
It’s impossible it seems to read anything about the Patient Centered Medical Home (PCMH) and not run into Community Care of North Carolina (CCNC) as the ‘The PCMH Saves Money’ poster child. No power point presentation on the topic is complete without its mention, no Meeting Agenda is full if it’s not there, if you’re going to testify on the PCMH’s benefits before Congress, you should bring it up , the Commonwealth Fund is working hard to replicate it and it’s even embedded in Medical Home Wikipedia.
Further, North Carolina and states that wanted to adopt this model were given an unprecedented 9-to-1 federal match, reflecting the Obama Administration’s admiration for its success.
