Home » Quality
Category Archives: Quality
In the age of spiritual machines Ray Kurzweil in 2001 predicted:
By 2020, a $1,000 computer will match processing speed of the human brain – 20 billion calculations per second
By 2030 it will simulate the brain power of a small village about 1,000 human minds
By 2048 it will have the brain power of the entire population of the US.
I predict that within 20-30 years the computer will replace the venerable physician. Computers can already be programmed to detect sarcasm and read emotions. They can study your face and body language. Computerized psychotherapists or cybertherapy is soon to come. Programs can detect deviation from the standard pattern of human physiology, thinking and behavior. We can already program standards of care and integrate it into an electronic health record. The U.S. government program of Meaningful Use is forcing the adoption electronic health record use in 3 stages by 2017. As always, encouragement is by reward initially, followed by penalty in the later stages.
Now as you sit in a doctor’s office, you are likely yourself talking to yourself rather to your doctor who’s not spending any face-to-face time with you. He or she is likely staring at a computer screen and typing notes as you speak. Because of physician shortages or need to meet RVU targets (unit measure of patient care), your doctor has 10 to 15 minutes to spend with you. During that time your doctor has to document all key elements of the visit and check off various measures Meaningful Use but if you are lucky, a minute will actually be spent on a limited physical exam.
Compare that with the experience you had when you were younger. Decades ago my old family doctor sat in front of me, talked to me and talked with me. He would jot a few notes on paper. I got an examination and a treatment plan. He made me feel as if I had spent a long time with him. I would call that “meaningful.”
As the government, health insurers and hospitals demand greater efficiency, more documentation and of course, error free care, it is in their best interest to replace us with machines. There will no longer be any medical errors, malpractice will become history, and your doctor won’t be exhausted or troubled with anything so trivial as feelings. Who needs that sort of interaction because you are only here for a service. In the near future, we will be talking to a computer with voice recognition. We won’t miss the warmth of a patient-physician relationship since that will have been bled from our experience and our memory. It would be like the depiction in the movie, Elysium, when Matt Damon talks to a computer rather than a human parole officer with hilarious results.
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.
Today I was notified by Medical Records at my hospital that one of my OR/surgery reports was incomplete. I had done hemorrhoid surgery on a patient 6 weeks ago. Someone in the medical records department flagged a deficiency in my OR note. I had left out the “drain” section – whether a drain was used or not. For my lay readers, you need to know that while drains can be used in abdominal surgery, I have never used one for hemorrhoid surgery in 27 years. In fact I can’t think of any colorectal surgeon ever using a drain for hemorrhoidectomy. In any case I was in violation as the hospital Medical Record Procedure Committee stated that Drain recording is a requirement and has to be addressed in the Operative report. I was directed to Rules and Regulations page 14. Was the documentation of drains a ‘requirement’ of the committee because of government regulatory agency rules or did the committee feel that drains should be used in hemorrhoidectomy? I doubt anyone sitting on this committee knows anything about anal surgery, so it’s likely a misinterpretation or misapplication of a badly written regulation. If this documentation of drains is required, then this should be mentioned in all surgery despite clinical relevance or common sense. Taking this to a ridiculous end in my hospital, drain use should be documented for anal fissure surgery, removal of rectal foreign body and colonoscopy performed in the OR in spite of logic that drains are never used in these procedures. It is thoughtless mindless enforcement of such ‘rules’ and regulations which lead to more and more doctors leaving medicine in frustration.