In the Time Magazine March 10 2014 edition there is an article on how the Affordable Health Care Act’s Healthcare.gov site was fixed.
When the healthcare.gov site was launched in October 2013, a mere hundred or so users caused the site to crash.
Typical of government led initiatives, the different sections responsible did not work in unison and there was no clearly identifiable person in charge of the site. Different parts did not know what was going on, so each assumed all was well and progressing forward. The Centers for Medicare and Medicaid (CMS) spent over $300 million on building a website that did not work. Their tech people forgot simple things like creating a cache, where most frequently accessed information is stored in a layer above the database. In that way queries could proceed quickly and not tie up the entire site – this is done in commercial sites.
The White House was forced to hire properly skilled tech folks from companies like Google to revamp the health care website. The newly hired consultants found that the original government designed site “hadn’t been designed to work right…that any single thing that slowed down would slow everything down.” Many of these troubleshooters fixed the site at a fraction of their usual pay. The lesson is that rich government contracts are awarded to incompetent cronies or to the lowest bidder. Since this is not a meritocracy, it’s unlikely that contracts would go to the most qualified at the onset. The good news for the government is that others can be hired later to do repairs.
Since originally there was no leader of healthcare.gov, we will never find out who was responsible for this mess and why so much money was wasted in the first place.
My hospital asked me to lead a quality initiative for rectal cancer using the ProvenCare model. ProvenCare uses evidence-based best practices to reliably give the best care to every patient. The goal is to reduce unnecessary variation in care, ensure all patients receive essential components of care and optimize patient outcome.
In 2003 Elizabeth McGlynn of the RAND Corporation published a study in the New England Journal of Medicine on the quality of care delivered in the US. Despite readily accessible standards of care in the literature, 45% of patients do not receive recommended care. This deficit in care is a threat to the health of Americans. It also represents unwarranted variation and inconsistency in care delivery, increases costs and affects clinical outcomes. Wouldn’t it be better if every doctor gave every patient the proper care at the right time, all the time?
My hospital rose to the challenge. With the help of a its electronic health record, it re-engineered the complex processes of care, reduced unwarranted variation and reliably delivered evidence-based care for specific diseases.
The ProvenCare model was first developed for elective coronary artery bypass grafting and hit the airwaves with revelation of a sort of money back guarantee. It has been used for bariatric surgery, hip replacement, cataract surgery, coronary stenting, lung cancer, with many other projects underway. Notably the lung cancer model was adopted by the American College of Surgeons’ Commission on Cancer and is being studied in 12 centers. The model came up with 38 elements of care based on evidence-based guidelines. Initial results show the initial six participating hospitals followed 90% of the 38 elements of care.
While some argue, mere compliance with process measures does not translate into better outcome, for many of the above diseases, Provencare has resulted in:
- Increased adherence to evidence-based guidelines
- Improved clinical outcomes
- Increased patient engagement
Rectal cancer represents a unique challenge. About 40,000 new rectal cancers are diagnosed yearly in the US and half will die from this cancer. While some may think most of these patients are treated at major cancer centers by colorectal specialists, only a small percentage receive such care. Most rectal cancer patients are treated by non-specialists in low-volume hospitals. As a result, there is a great variation in how the care is delivered and a great variation in the outcome. The literature shows that local recurrence can be as low as 0% and as high as 37%. Surgical mortality varies between 1.4% to 7% at the high end. The colostomy rate also varies throughout the country. Rectal cancer surgery is difficult as the cancer can be low, confined by a narrow bony pelvis. This can result in incomplete removal leading to local recurrence and death or hinder making an anastomosis (putting the rectum back together).
In addition to the surgical problems, patients should have high quality imaging of the tumor with either endorectal ultrasound or pelvic MRI but many hospitals do not have these tools. Some patients may need radiation and chemotherapy before or after surgery and may never receive it. Some could benefit from a multidisciplinary approach where each patient’s case is reviewed by a team of surgeons, medical and radiation oncologists and other providers. If that patient’s hospital does not have such a team, that team approach is not offered. After surgery accurate assessment of the tumor stage and the margin (how deeply the cancer invades the rectum) affects prognosis and treatment planning. Ideally this is best done by specially trained pathologists which can ensure the quality of the surgery.
So with a team of ProvenCare specialists, the rectal cancer project is underway. This plan will take about 40-50 weeks, with a meeting every week. The project is in 7 stages and presently we are reviewing the literature to identify the ‘best practices’ of rectal cancer care.
As each stage unfolds, I will continue to write about the process.