Archive for January, 2013
Question: What is the number one reason people see doctors?
- a) because they have a life threatening health problem
- b) because they are obese and want to lose weight
- c) because they don’t get enough exercise and want an exercise program
- d) because they have a skin problem
According to an article in the Mayo Clinic Proceedings this month the answer is “d”. 42.7% of visits are due to skin disorders. You should have known the answer just by looking at the magazines at the grocery checkout counter or watching ads on TV. We worry about skin blemishes but in the past people had to worry about smallpox or TB. It is hard to be serious about health care cost and political change in the face of this statistic. OK, acne scars are bad and skin cancer is real. But, the real danger from skin problems is very low. What can be done to alleviate skin problems without spending half of the U.S. GDP on trivial office visits?
The Mayo Clinic Proceedings article tangentially mentions dermatology telemedicine. Great idea. A picture is indeed worth a thousand words or perhaps a thousand patient visits. What if there was an app for taking a picture of a skin lesion and sending it for a dermatology consult ($10). Think of the cost savings for simple advice for acne or eczema or diaper rash! The improvement in health literacy would be huge and visits to primary care would decline. If a visit to primary care proved to be needed it would be for a substantial skin problem (or something else). Any health system wanting to reduce cost should find this idea fantastic — any health systems out there actually doing this?
The above graph is from a recent publication of the Institute of Medicine entitled “U.S. Health in International Perspective: Shorter Lives, Poorer Health (2013)”. The graph depicts the causes of death for males less than 50 years old. Compared to other wealthy countries the U.S. life-expectancy ranks 17th for men and 16th for women According to the report “The tragedy is not that the U.S. is losing a contest with other countries, but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.” Several causes were cited including lack of insurance, lack of access to primary care, high poverty rate, poor diet, lack of exercise and use of firearms in acts of violence.
Although the report is blunt enough the bottom line is we have good doctors, good nurses, good medications, good equipment, good hospitals, and good clinics but we have poor management of our health care system. The equation is:
Good Providers + Bad Management = Bad Health Care
You may ask: what is health care management? In a word a “PLAN” or simply coordination of action — we truly do not have a health care system. We have a variety of types of insurance, government programs and fee for service (i.e. no money no service). Even the very wealthy get poor health care because of a lack of quality management. Some States do much better than others. If Minnesota was a country it would rank near the top. If Louisiana was a country it would be a third world country ranked near the bottom.
One of the big political concerns is cost. We pay more for health care than any other country. One third of our cost is attributed to waste (i.e. paperwork). When a system is poorly coordinated the cost is high. So, why would any country spend more money on such a system?
The above report is just another in a long series of bad reports on U.S. health care. Although the Affordable Care Act (Obama Care) is helpful it will never move life expectancy to the top of the list.
There are lots of solutions. But, they all require planning and system thinking. Trying to solve one problem at a time to evolve a better system will take about as long as human evolution. Perhaps in a million years we will have evolved beyond illness — yes, that’s the plan.
Diagram of the Multi-Team System (MTS) for patient care is from the AHRQ web site. This is an idealized concept of what should happen that often does not happen.
A recent article in the New England Journal of Medicine (NEJM) described an unfortunate but all too common situation in hospitals. In this article a patient was very sick in the intensive care unit with respiratory failure (on a ventilator) and with an unusual skin rash. 40 doctors and far more nurses were involved in the patient’s care. So many people, in fact, that nobody knew who was in charge and except for ordering more and more tests nobody did anything. The NEJM article sites the “Bystander Effect” which is the tendency for everyone in a big group to assume someone else will act. Finally, the patient was saved by an acute problem which forced a doctor on the spot to actually do something.
Quality care is doing the right thing at the right time. On both counts the NEJM case represents low quality. Other factors beside the “Bystander Effect” may have been at work. Perhaps the “Silo Effect” where all the care givers were in their own silo without regard to the big picture. Perhaps it was the “Swiss Cheese Effect” where errors on several levels lined up and the patient fell through. But, most likely, the low quality was due to poor communication — the usual suspect. If the care team does not talk the sense of urgency and the sense of danger are lost. The patient was in grave danger!
So, you think this would never happen to you or happen at your local hospital? Think again. It happens all the time when more than one doctor is involved (including on-call doctors). Are there solutions? Yes. The most desperate need is always to designate who is in charge for every minute and every hour and every shift — including doctors and nurses. In-charge is not a title, it means willing and able to act. There should be a sign in each patient’s room with the name of the in-charge doctor and in-charge nurse. Also, there should be a sign on the intensive care door: “All consultants who enter must talk to the doctor in-charge before leaving”.
On a more hopeful note, research has some useful ideas for the teamwork-challenged hospital. Here are some pre- and post-shift check lists from the STEPPS program:
During the brief, the team should address the following questions:
___ Who is on the team?
___ All members understand and agree upon goals?
___ Roles and responsibilities are understood?
___ What is our plan of care?
___ Staff and provider’s availability throughout the shift?
___ Workload among team members?
___ Availability of resources?
The team should address the following questions during a debrief:
___ Communication clear?
___ Roles and responsibilities understood?
___ Situation awareness maintained?
___ Workload distribution equitable?
___ Task assistance requested or offered?
___ Were errors made or avoided? Availability of resources?
___ What went well, what should change, what should improve?
The question of “who is in charge” is critical for hospital care. Trauma surgeons seem to have this issue mastered (they are in charge) but other doctors are in a quandry when more than one is involved. Patient safety demands US hospitals do better!
Finally, a comment about cost. The lack of someone in-charge leads to high cost. The NEJM article itself failed to mention the cost of 40 doctors working on the case. In this time of rising health care cost the nation can not afford such lavish use of resources.
The above map comes from Internal Medicine News. State by state it shows where doctors are using electronic prescribing. A simple question for those doctors in the white states: why live in the past? Huge numbers of pharmacies accept electronic prescriptions, patients like electronic prescriptions better than paper prescriptions, prescribing errors are much lower, patients get better care, drug interaction checks can be done BEFORE the prescription is sent (so the pharmacist does not have to call), and a record of the prescription is available as part of the medical record.
The doctor perspective: “Just more computer work for me”
The patient perspective: “I like the idea of fewer errors”
How does it work?
The prescriber needs to have several things in place:
- An electronic medical record
(without this much of the advantage is lost)
- An electronic list of the patient’s active prescriptions
- An electronic list of the patient’s allergies and intolerances
- A diagnosis associated with the prescription
- A record entry to document the thought process for the prescription
- An internal link to the insurance drug formulary
A very good process is to have the computer screen for prescribing where the patient can see the actions of the prescriber. That way the patient can see what is being prescribed, whether it is covered by insurance, where the prescription will be sent, the instructions, the amount and the refills. If there are problems the patient can comment — it is much better to have feedback at the time of prescribing rather than the patient not take the medication or get phone calls later with questions from the patient or pharmacist. Physicians who use e-prescribing don’t ever want to go back to the old way! Pharmacists never liked physician handwriting anyway.
So, if your physician is not using e-prescribing give them a copy of this post!