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Saturday, January 28, 2012

Preventing harm from healthcare - where are we?

I'm reading Sorrel King's book "Josie's Story" about her beautiful little girl - less than two years old - who died at Johns Hopkins several years ago as the result of avoidable errors in her care.  This is a story that I have heard many times, including Ms. King's own account from the podium at large meetings such as those of the National Patient Safety Foundation. She has been a tireless advocate for patients and for making healthcare safer, a reminder to all of us that behind every statistic is not just a life but many lives, the brothers and sisters, mothers, fathers, sons and daughters of those who have suffered from medical errors and their aftermath.

I have been studying medical errors and patient safety for more than ten years, and I still don't understand it.  None of us do.  We know a lot more than we did a decade or two ago.  We know that medical errors and harm are not rare, comprising, in fact, a leading cause of death in this country.  We know that most occur while patients are receiving care from very well trained, committed and diligent professionals, and often happen in the nation's best respected Centers.   Meaning that everything we thought before - that such accidents are rare, and that they are generally traceable to "bad apple" doctors and nurses with deficient skills, an inclination to negligence, or both - that these assumptions were pretty much dead wrong.  

We also know that preventing healthcare-associated harm - from medication errors, missed diagnoses, delayed intervention, hospital infections, wrong site surgery and more - involves not one approach, but many.  Because the "war on harm," we now know, is a lot like the "war on cancer."  Just as "cancer" is many different conditions, so "errors" come in many forms, affecting patients in many ways.  And we are still learning about the causative factors, so that effective changes can be implemented, both locally and nationally.

Despite this complexity, however, we have learned to look at healthcare delivery in new ways that provide coherence to our War on Harm.  They involve how we design processes, the role of communication, organizational culture, the role of patient empowerment, and leadership.  More on this in future blogs.

Thursday, January 26, 2012

Combining the past with the present to invent the future: your medical home

Can you reach your physician, or an informed and responsive surrogate, any time you have a question?  And if you need a same day visit, can you count on getting one?  Are you treated like a mature adult who is in charge of your own healthcare decisions?  If you are seeing one or more specialists, does your primary care physician coordinate your plan of care and help you understand it? Can you access your own records online?

Despite islands of excellence, contemporary healthcare falls short in providing the kind of patient-centered, coordinated, efficient and accurate care that our nation deserves and that is within our reach.  Not only do the current deficiencies frustrate patients and care givers alike, but our fractured system adds enormously to the cost of care. Ours is a high-cost, low-value system that many have criticized as being not a system at all.

Enter the "Patient-Centered Medical Home".

Arising from concepts first articulated by the American Academy of Pediatrics, PCMH is a model of care that describes a role for the primary care physician and his team that goes far beyond the "gatekeeper" economic model of the 1990s.  To be a PCMH, a primary care practice must provide comprehensive, team-based care that meets the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care provided by a cohesive team. 

This care must be coordinated across all elements of the complex health care system and connect patients to both medical and social resources in the community. It must include superb access to care that meets patients’ needs, including care provided after hours and by e-mail and telephone.  Finally, it must encourage self-care and empower patients and families to be active decision-makers to ensure that the healthcare provided is consistent with the needs, values and preferences of the patient.  

Why did this model originate in Pediatrics, when so many more adults than children have chronic diseases and the desperate need for this kind of care?  First, I think pediatricians have historically been oriented toward health maintenance, education and empowering families.  Second, and this is just my personal conjecture, when it comes to coordinating the care of patients under the care of one or more specialists, we pediatricians have been better able to practice to the "gold standard" if only because such a small fraction of our total population requires this intensive (and uncompensated) work.   

However it started, the PCMH concept is getting serious attention by thought leaders in Washington and across the healthcare scene.  At the risk of sounding like a pediatrician, it sure seems like a good idea to me.  Look for more details on the Patient Centered Medical Home at

Saturday, January 21, 2012

Building Better Doctors

A 45 year old gentleman sits on the examination table.  He has come to his physician with a complaint of "chest pain."  Through careful probing, the doctor, a young woman with straight long dark hair, horn rimmed glasses and a long white coat, discerns that the man awoke with this pain after falling the evening before.

"What were you doing," she asks.
"Well, I was just crossing this parking lot, and looking over my shoulder, and I guess I fell over this parking know, the concrete thing..."
"Where were you coming from," she persists.
"What kind of place is that?"
"Oh, it's a bar."

By the end of a short interview, this skillful clinician has done more than could be accomplished with a battery of lab tests or a CAT scan:  she has discerned that what started out as a visit for "chest pain" is really about an individual who drinks in the morning, has had previous alcohol-related injuries and is on the outs with his wife over his addiction.

The really remarkable thing about this clinical encounter:  the man is not a patient; he is an actor, otherwise known as a "Standardized Patient." And the talented "doctor" isn't a doctor, at least not yet.  Instead this remarkably able clinician is just twelve weeks into her first year at the new Hofstra - North Shore LIJ School of Medicine.

As a matter of disclosure, I am a proud member of the faculty at the School of Medicine, which is founded on principles of humanism, patient-centeredness, and lifelong professional growth, all promoted in a learner-driven environment of collaborative discovery.  The goal is to mint the kind of physicians we all want taking care of our loved ones and, when the time comes, ourselves.  In future posts I'll tell you more surprising things about what's happening at the SOM.

Saturday, January 14, 2012

Hospitals, Doctors and Patients in the Labyrinth of Healthcare Finance: The Case of the Patient Who Was Neither Admitted Nor Discharged

Your husband awakens with chest pain and you head to the local Emergency Department.  The team there performs an immediate EKG and obtains some blood for testing.  So far, there’s no clear evidence for a heart attack, so an immediate angioplasty is not in the cards.  You’re both relieved. 

A little while later, a young physician in a starched, ankle-length white coat comes to meet you, and introduces himself as the on-call cardiologist.  We’ll call him Dr. Harvey.  He tells you that so far things look pretty good, but some additional tests would be prudent.  His advice is that you not go home.  “So you’re admitting my husband to the hospital?” you ask.  “Not exactly.”

Under federal rules that are being enforced with increasing vigor, hospitals and their staff physicians must consider not two, but three pathways for patients who arrive with problems like chest pain, loss of consciousness and others:  discharge from the ED, in-patient admission, or “Observation Status.”

According to guidelines issued by the Center for Medicare and Medicaid Services (CMS), Observation Status is appropriate for patients who do not meet certain defined criteria that are required for the more familiar disposition of admission to an in-patient service.   Such patients are generally expected to have lengths of stay less than one day, and to require less complex services.   Failure to exercise this option where appropriate now subjects hospitals to fines and penalties that can be substantial.

Although the guidelines describing “Observation Status” have existed for some time, candidly, hospitals and doctors have not until recently focused on identifying patients that should fit in this category.  The reasons?  First, hospitals receive lower reimbursements for Observation, even though the short-term resource investment is high (hourly reassessment and documentation by the nurse, and at least six physician visits in 24 hours.)  Second, Medicare patients are typically better off with an in-patient stay, because larger co-payments apply for “Observation” patients under Medicare rules that hospitals do not control.  So the hospital loses (which, for our nation’s many healthcare non-profits is a significant issue) and so do patients. 

As a hospital executive, I worry that not a single episode of “ER” or “Chicago Hope” ever touched on this matter, so our patients are likely to be in the dark until our Finance representatives try to explain the bill.  Of course, as citizens we all realize (or ought to) that healthcare “spend” in this country is way out of control and that efforts to reduce it it are a must.  With or without President Obama’s Affordable Care Act this is a national problem of unprecedented scale. More on this another time!

Friday, January 6, 2012

The killer most have never heard of

"Sepsis." This is, after all, the second decade of the 21st center. Could severe, overwhelming infection be more than an anomaly? Could it still be an important cause of death? 

Not only are these infections often fatal, but the rate of severe sepsis is increasing.  Who is at risk?  Persons at the extremes of the lifespan.  Premature infants (and to a lesser extent, infants up to a year of age). And seniors.  1400 persons die each day of sepsis worldwide.  This is a greater incidence than death from breast cancer or colon cancer.  And this rate is increasing due to the use of advanced treatments for elderly patients and the increasing life span.

Sepsis involves an interaction between the body's immune system and invading organisms, most often (though not always) bacteria.  When the body's own infection-fighting forces spin out of control, the result is damage to organs and collapse of the life sustaining circulatory and respiratory systems.

The contemporary management of sepsis involves early recognition (of signs of infection plus evidence of organ system dysfunction) and early intervention with intravenous fluids, broad-spectrum antibiotics, and sometimes other medications that regulate the heart and circulation.

I am very proud that Huntington Hospital and the North Shore LIJ Health System are collaborating with the prestigious Institute for Healthcare Improvement (IHI) in a new project to reduce sepsis mortality by 50%.   At a meeting in Huntington earlier today, hospital, Health system and IHI leaders discussed next steps to optimize early identification and intervention for this important condition.  Our successes in this area of quality improvement and research will not only benefit the members of our community, but also pave the way to spread knowledge and improved practice on a national level.

Sunday, January 1, 2012

Top ten tips for positive parenting in 2012

Number 1.  And the winner is...

I shouldn't decide this one on my own.

Gentle readers, there are as many paths to positive parenting as there are to positive change in any other sphere of life.  So I appeal to you to write a response.  (Being an actual parent is not a requirement; in the real world, lack of personal experience doesn't dissuade most people I know from sharing opinions on this topic!)

In the meantime, my very warmest wishes for a positive, healthful 2012, filled with love and fulfilling work!