March 12th, 2007 by Dr. Val Jones in Health Policy
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In my last post I described a form of short hand that we docs use to communicate. One of my readers sent me a personal note via email. I thought she made some excellent points, so I’m going to post them here (with the silent conversation going on in my head when I read it typed conveniently in ALL CAPS).
The modern day pace is so incredibly stepped-up nowadays that it makes me nervous about human error. YOU SHOULD BE AFRAID. When doctors don’t have time to write complete words on paper, do they have time to give your case enough thought? PROBABLY NOT. Will some important detail slip past them? SURE. Will they make a mistake because they misread one of those code letters? NO, I DON’T THINK SO, THERE ARE PLENTY OF BETTER WAYS TO MAKE MISTAKES, LIKE GRABBING THE WRONG CHART. I should think that would be easy to do when doctors have terrible handwriting due mainly to haste. DON’T KID YOURSELF, THEIR HANDWRITING LOOKS EXACTLY THE SAME WHEN THEY HAVE ALL THE TIME IN THE WORLD.
All jest aside, we are in a serious quandary here… the poor primary care physicians in this country are totally swamped, they are under extreme pressure to see more patients in a day than should be legal, and in the end the patients suffer. At a certain tipping point (let’s say 12 patients/day) speed really does become inversely proportional to quality.
Instead of developing complex pay for performance measures, why not find ways to incentivize docs to see fewer patients? Truly, quality would automatically improve, patients would learn more about how to manage their chronic diseases, and docs would be happier and more productive. The quality police fail to recognize that time is the key to improving care. Can we really afford to keep up this frantic pace?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 3rd, 2007 by Dr. Val Jones in Health Policy
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Improving quality in healthcare is an important fundamental goal. New “pay for performance” measures initiated by the Center for Medicare and Medicaid services is a well meaning attempt to provide financial incentives to physicians who demonstrate improved patient outcomes. Unfortunately, this incentive program could backfire.
A recent article in Medical Economics (via Kevin MD) raised the question of “cherry picking and lemon dropping” your way to higher pay. In this frightening scenario, physicians would be tempted to select healthier, more compliant patients for regular treatment in their practices. In this manner, they can demonstrate better outcomes, since the sicker, poorer, or less compliant patients no longer factor into their performance measures. And with the upcoming physician shortage, it really is a seller’s market.
It is critically important for the government programs to allow physicians to accurately risk stratify their patients so that they are not financially penalized for taking care of sicker patients bound to have below average outcomes. The same goes for surgeons, who should not be discouraged from undertaking potentially lifesaving surgeries for patients who are critically ill.
Dr. Kellerman, the president of the American Academy of Family Physicians, reminds us that quality of care is vastly improved by having a central medical home (i.e. one physician who can coordinate care for patients, so they’re not left with a group of disconnected specialists ordering duplicate tests and prescriptions). I personally think that a centralized EMR/PHR controlled by the patient (and located at an Internet based “medical home” complete with disease management tools and the ability to email a physician as needed) would go a long way to improving quality.
What do you think?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 26th, 2007 by Dr. Val Jones in Opinion
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One of the great advantages of electronic medical records (EMRs) is that they can reduce unnecessary repeat testing. Without an EMR that is accessible to all physicians taking care of a single patient, there’s no way for them to know what the other one is prescribing. Expensive tests like MRIs are often ordered by two different physicians (a neurosurgeon and a rehabilitation medicine specialist for example) because one didn’t know that the other had already ordered it. Alternatively, they may be affiliated with institutions that don’t share data, so previous MRI images are not available for viewing by the new specialist – so she just orders another one.
However, an interesting question is raised by Dr. Perloe’s post to my last blog entry: what if all specialists taking care of a patient had access to one medical record – and there was a lab error? They would all rely on the same erroneous record, and this could spark a whole host of inappropriate tests and procedures. Even second opinions (based on one single record) would be less helpful – because they would be misled by false results.
So, the irony is that the redundancy in our system has its benefits. We should be mindful of the checks and balances that we are unwittingly removing with EMRs. Occasional lab errors will always be with us – let’s make sure we catch them early, and not commit them to a permanent record relied upon by all.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 25th, 2007 by Dr. Val Jones in Opinion
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Our Chief Privacy Officer sent me an interesting article today about how hospitals are promoting “disclosure and apology” (by physicians to patients or their families) when a medical error is committed. The report suggests that less money will be spent in malpractice suits if physicians fess up to their mistakes instead of trying to hide them.
Another study suggests that 99% of physicians believe that it is morally right to confess errors to patients and family members, but that only about 33% report doing so. The article says that the number one reason why they don’t report errors is fear of being sued.
While these statistics don’t reflect well on physicians, I think there’s some murkiness here that’s worth reviewing. First of all, what constitutes an error? When a young resident physician performs a procedure in an inferior manner due to lack of experience, is that an error? When a code team is not called soon enough because a patient doesn’t appear gravely ill initially, is that an error? If an unconscious patient arrives in the ER and is treated with a medicine that causes a life-threatening allergic reaction, is that an error? I think that many times physicians perceive some “errors” as unfortunate and regrettable aspects of the natural practice of medicine and don’t report them formally.
Another reason why physicians may not report errors is because it’s unclear that the error has a specific adverse effect – perhaps a patient’s Tylenol was given at the wrong time of day. That’s an error – but is it worthy of formally reporting it to the patient? What about when the lab loses the tube of blood drawn from a patient? Should the patient be told about it or should the labs be added to the next day’s scheduled draw?
The majority of “errors” that I’ve witnessed are in the realm of sub-optimal care due to inexperience, inattentiveness, or misinterpretation of test results. However, errors of the sort that result in death and serious harm appear to be alarmingly frequent (some studies argue that there are 40-90 thousand of these errors per year).
I think that physicians should always tell patients the truth about their care, the risks associated with certain procedures, and the full range of choices that are available to them. I do believe that patients value (and deserve) to know the truth - even when it makes the physician or hospital seem less than perfect. In the cases of errors that result in serious consequences – honesty is the best (and only) policy.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
