Posts Tagged quality care

Telemedicine — the good, the bad and the ugly.

noseviewTHE GOOD:  If your brother is a doctor and you call him for medical advice that is probably good Telemedicine.   The doctor clearly has your interest at heart, you can call again, the doctor will likely look up information and will probably give you some Internet links to check out.  And, the doctor does not want to make you upset or interfere with the relationship you have with your actual doctor.  Good idea, except doctors will not usually prescribe for a relative, or should not.

THE BAD:  The same things wrong with actual provider interactions can still be wrong on video — not being given enough time to state the problem, not enough patient education, not enough of a partnership, and poor follow-up.  Also, prescribing antibiotics for viral infections (the common cold) can be even a greater temptation by video.

THE UGLY:  A low position of the video camera that seems to look up the doctor’s nose — yes, that’s ugly.

The most common reasons for visits to a health care provider are: cough, joint pains and skin conditions.

Evaluation of cough by telemedicine is difficult because it requires looking in the nose, ears and throat and listening to the lungs for wheezing or other sounds.  This is better in person.   Although, a telemedicine follow-up might be just fine.

Evaluation of joint pains is fairly easy with telemedicine.  For example, back pain is usually temporary and x-rays are not advised.  It’s easy to suggest ways to avoid straining the back and be encouraging.  Treatment usually involves over-the-counter medications.

Evaluation of a skin condition also is fairly easy with good quality video.  Diaper rash and acne are no-brainers.  But, trying to separate skin cancer from a benign seborrheic keratosis is a little harder — probably best left to an office visit.

Follow-up visits for lots of things can be done by telemedicine.  A follow-up visit for congestive heart failure can be done by video especially if the patient has a reliable scale at home.

Follow-up visits consume valuable office time that could and should be allotted to new or serious problems.  The phone will often work just as well.  Telemedicine visits can be done when office staff is not working — thus at a much lower overhead cost.

Provider-to-consultant video conferencing is a great idea.  This works particularly well if the two individuals work in the same organization.  If they are not in the same organization financial issues often get in the way.

A fine example of peer-to-peer video conferencing is in the UK where groups of NHS neurosurgeons at one hospital communicate with groups of NHS neurosurgeons at another hospital sharing x-ray images and and clinical details.  Very difficult decisions are often better with input from colleagues — and consistency of care is improved.

Telemedicine does not solve bad-care problems.  Switching bad-care in person to bad-care by video is not helpful.

Telemedicine can reduce the cost of care for simple issues that mainly need better health literacy and for follow-up of known health problems.  The capacity of health care is not adequate in many countries (including the US).   Telemedicine is a provider-extender and needs to be used a lot more.

 

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Hospitals fail to stop IV fluids for CHF — poor quality care

ivfluidsHospitals are responsible to rescue patients from inappropriate treatment — especially when the need to intervene is obvious.   The hospital has a board of directors responsible for the care delivered in a hospital. They hire the CEO who hires a quality manager.  When bad quality management hurts or kills patients it is the hospital’s fault.

An article by Dr. Behnood Bikdeli and colleagues (JCHF. 2015;3(2):127-133) describes a huge study at 346 hospitals about treatment of patients with congestive heart failure (CHF).   Here is the essence:

  • CHF is life-threatening condition where the body collects too much fluid, usually due to a weak heart.  The fluid gets into the lungs and causes shortness of breath.
  • The treatment for CHF is to remove fluid from the body and give medications to improve heart and kidney function.
  • The absolutely wrong thing to do is to give extra fluid by the veins.
  • The study found about 12% of patients with CHF were treated with 1 to 2 liters of fluid in the veins during the first 2 days of hospitalization.  AND, most alarming, compared to similar patients not treated this way, they were more likely to end up in intensive care or die.
  • The most telling statistic is how often various hospitals let this dangerous use of intravenous fluid happen:  0% to 71%.  This means some hospitals did not let it happen (0%).  Some hospitals let it happen a lot (71%) — just hope your grandmother did not go to that hospital!

It is not rocket science to say fluid overload is not treated with extra fluid.  This is easy to detect when the admitting diagnosis is CHF and the doctor orders say “NS IV at TKO” (translation:  give salt water in the veins at a rate to make sure the veins stay open).  NO NO NO the patient does not need extra fluid.  This should not happen and there are lots of ways to prevent it or even rescue patients when Dr Welby writes such an order (or tries to use leaches).

Solutions:

  1. Mandate doctors use standard orders for treatment of CHF — there is plenty of latitude to customize such orders.  But, IV fluid is not one of the choices without stating why.
  2. Educate staff that IV fluid is not required to admit a patient (an old fashioned insurance rule).
  3. Educate staff that IV fluid is not a cure-all.  Fluid would help a dehydrated patient but not others.
  4. Nurses do a double check before admitting a patient from the ER with the question:  does this patient have CHF and an order for IV fluids — if so, call the physician to clarify the situation or to change the order — no clarity=no admit.
  5. All CHF patients should be weighed daily — if the weight is going up it means more fluid is being retained — the patient needs to be rescued.  Fix the problem or find someone who can, NOW.

Attention patient and family.  This is easy to spot.  The admitting doctor says the diagnosis is congestive heart failure but you see IV fluids being pumped into yourself or your family member.  SPEAK UP!  “Why is fluid treatment needed?”  do not accept the answer of “everybody gets an IV”.

Attention hospital board members:  do you know what your hospital is doing to prevent this obvious problem?  Quality is your responsibility, you must do something besides listen to financial statements.  Is your hospital the one with 0% or 71% record of treating CHF with IV fluids?

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Direct Primary Care — where’s the quality?

greedydoctorHappy doctors seeing fewer patients and making more money — what’s not to like?  According to author David Von Drehle’s article “Medicine Gets Personal” in Time Magazine, Dec 29/Jan 5, the results are “intriguing”.

The story is about Qliance Health in Seattle founded by two doctors who were dissatisfied with fee-for-service medicine and all the associated paperwork.  So, they developed a model of care where the patient pays $65/month and receives all the primary care they need.  And, as a twist, they also agree to see Medicaid patients for the same cash amount (the details of the arrangement were not stated in the article).  Of course, insurance and medicaid pay for all other services like tests, x-rays, drugs, hospitalizations and specialists.

The doctors are happy because they have less oversight from insurance, don’t have to collect any data to prove they are delivering quality care, get steady income, treat patients over the phone to minimize visits, and are able to “run” their own business with no boss.  For the libertarian-minded physician it’s nirvana.

Piece-work is indeed a hard life as physicians and many in the garment industry know.  A monthly salary is much easier on the worker.  And, the salary model is not new in terms of primary medical care.  The physicians working for the National Health Service (NHS) in the UK have had this system since WWII.  However, the NHS found it was necessary to add financial incentives to get the doctors to do enough work.  And, they found it necessary to monitor quality since quality slips without oversight.

So, this “Direct Primary Care” is not new in the world.  In fact, it may be an important part of an Accountable Care Organization (ACO) as being tried the US.  But, physicians need to realize they need to be part of a large organization to ensure quality care.  The future for primary care is to be an employee, not a mom-and-pop store.  Most of doctor’s patients work as employees, is that so bad?

$65 per month would be too much to pay for poor quality care (the cost of poor care is always too high!)  So what does “Direct Primary Care” need to do for patients and payers to be confident quality care is being delivered?

  1. Measure and report quality in a transparent way — like on the office website.  And, keep it updated.
  2. Deliver patient-centered care and prove it.  Survey patient’s expectations and record whether the expectations are met with office visits.
  3. Report quality indicators other doctors must do like for diabetes, hypertension and smoking.
  4. Report primary care specific indicators regarding the most common diagnoses — skin conditions, joint pains and respiratory infections.
  5. Take a financial stake in what is prescribed or ordered.  Pay some fraction of the cost of all medications prescribed and all tests ordered.  They need to have some “skin in the game”.  (So there is a connection to the larger world of health care cost — ordering a $1000 MRI scan for every ache and pain must have some consequence).

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Doctors and Warfarin — patient expectations

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Bill(*) had a really bad headache and died before he could call 911
.  He died of a complication of warfarin which he was taking to prevent blood clots.  Instead, the best intentions to prevent a stroke lead to uncontrolled bleeding in the brain, high pressure inside the skull and death.

Warfarin and other anticoagulants are necessary medications but also dangerous medications.   People take the medications because the risk of blood clots, for them, is higher than the risk of anticoagulation.   The last thing a patient wants is for drug management errors to tip balance so the risk of the medication is too high.

So, what are the expectations of people who take warfarin?  What do they expect of their providers?  What do the providers expect of them?

  1. Patients expect providers to follow drug guidelines to the letter
  2. Providers expect patients to follow instructions and learn about warfarin
  3. Patients want to be in the loop — meaning the risks are high so they want to be in a position to make sure the necessary communication happens and dose adjustments make sense.
  4. Providers need to be able to contact patients and expect positive feedback — “message received, will change dose to ___ as directed”
  5. Patients expect a consistent process no matter the day of the week or which provider is on call.
  6. Above all, patients expect adequate prevention and minimum risk.

Here are several marks of quality warfarin management:

  • The same day of drawing lab (INR)  the patient is informed 1) the result  2) the change in dose and 3) the date of the next lab.  Finger-stick methods with quick results allow some offices to provide instructions before the patient leaves the office.
  • The patient is asked to keep a record of results and instructions.  And, to “read back” the instructions.  Thus the provider knows the patient got the right message.
  • The patients have the phone number to call for any evidence of abnormal bruising or bleeding.  They should expect to get lab tested or go to the emergency room.
  • There is no impediment to getting the warfarin prescription refilled when needed.
  • Providers use computer applications or paper tables to select the correct warfarin dose.  Only if there are unusual problems do they deviate from established guidelines.
  • If the INR is out of range the dose is changed and the INR is rechecked within a week — even if the patient was on a monthly lab routine.
  • The day the INR is checked patients do not take the usual warfarin dose until the results are available.
  • Providers never say “just keep taking the same dose unless we call you”.   That is a recipe for disaster if a lab test is lost or sent to the wrong provider.
  • The lab the patient uses is open 7 days a week.
  • Providers instruct patients to follow a consistent diet so the amount of vitamin K in the diet is fairly constant.  A sudden drop in vitamin K intake causes the INR to rise and bleeding risk to increase.

Back to the case of Bill.  He forgot to get his INR checked on Friday and nobody called him to check why.  He knew the lab was not open on the weekend.  The nosebleed was unusual but not too bothersome — besides, his doctor was not on call and he did not know who to call.  He took a slight fall and bumped his head – he didn’t think small head injuries were risky.  He had a good memory but sometimes forgot how many warfarin pills to take on Saturday so he took 2.  Wrong, wrong and wrong. The outcome might be better if the medical process was better and if patient education was better.


(*) Bill’s case is not real but such deaths have been reported.  It is true warfarin is related to rat poison.

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