As I travel around the country, working in the trenches of various hospitals, I’ve been struck by the number of errors made by physicians and nurses whose administrative burden distracts them from patient care. The clinicians who make the errors are intelligent and competent – and they feel badly when an error is made. However, the volume of tasks required of them in a day (many of which are designed to fulfill an administrative “patient safety” or “quality enhancement” process) makes it impossible for them to complete any task in a comprehensive and thoughtful manner. In the end, administrators’ responses to increased error frequency is to increase error tracking and demand further documentation that leads to less time with patients and more errors overall. It’s a vicious cycle that people aren’t talking about enough.
As I receive patient admissions from various referral hospitals, I rarely find a comprehensive discharge summary or full history and physical exam document that provides an accurate and complete account of the patient’s health status. Most of the documentation is poorly synthesized, scattered throughout reams of EMR-generated duplicative and irrelevant minutiae. Interpreting and sifting through this electronic data adds hours to my work day. Most physicians don’t bother to sift – which is why important information is missed in the mad dash to treat more patients per day than can be done safely and thoroughly.
I have personally witnessed many critical misdiagnoses caused by sloppy and rushed medical evaluations. I have had to transfer patients back to their originating surgical hospitals (at some of America’s top academic centers) for further work up and treatment, and have uncovered everything from cancer to brain disorders to medication errors for patients who had been evaluated and treated by many other specialists before me. No one seems to have the time to take a long hard look at these patients, and so they end up undergoing knee-jerk treatments for partially thought through diagnoses. The quality of medical care in which I’ve been engaged (over the past 20 years) has taken a dramatic turn for the worse because of volume overload (fueled by diminishing reimbursement) in the setting of excessive administrative and documentation requirements.
To use an analogy – The solution to the healthcare cost crisis is not to increase the speed of the assembly line belt when our physicians and nurses are already dropping items on the floor. First, stop asking them to step away from the belt to do other things. Second, put a cap on belt speed. Third, insure that you have sufficient staff to handle the volume of “product” on the belt, and support them with post-belt packaging and procedures that will prevent back up.
What we require most in healthcare is time to process our thoughts and engage in information synthesis. We must give physicians the time they need to complete a full, comprehensive, evaluation of each patient at regular intervals. We need nurses to be freed from desk clerk and safety documentation activities to actually inspect and manage their patients and alert physicians to new information.
Until hospitals and administrators recognize that more data does not result in better care, and that intelligent information synthesis (which requires clinician time, not computer algorithms) is the foundation of error prevention, I do not foresee a bright future for patients in this manic assembly line of a healthcare system.
Well, you knew it was only a matter of time until the press started covering the court of public opinion – meaning polls. This story came out last night from the Houston Chronicle entitled, “Poll shows falling support for health care reform.” It seems as if the University of Texas Health Science Center at Houston and Zogby International – have found that public support for congress and health care reform seem to be declining.
The authors conducted an online poll that found 50 percent of respondents oppose a bill introduced by U.S. House Democratic leaders this week that would overhaul the system and pay for it by raising the taxes of the wealthiest Americans. Forty-two percent said they support the bill.
Now, I know what people say at this point – it’s bad data – who was the polling sample of – blah, blah, blah. One poll says this and another poll says that – who do you believe? It doesn’t matter who you believe. It matters who the people inside the beltway believe as they start to see these numbers come out.
The poll shows there is strong support for providing insurance for all Americans, but little for increasing taxes to pay for it. Increasing cigarette taxes was favored by 50 percent of respondents, the only tax option favored by at least half of respondents. Less than 20 percent favored increased co-pays and deductibles, rationing care, eliminating Medicare Advantage plans and decreasing home care reimbursement.
Does anyone really think that this will all be done by the August recess? As usual, the strategy is to push something through the House, something through the Senate, and the real bill be decided behind closed doors in conference committee. It worked with the so-called “stimulus” bill. But reading the quotes coming out of the Senate, a lot of people, on both sides of the isle are uneasy with this time frame. Each day gets more interesting, and not in a good way.
*This blog post was originally published at Doctor Anonymous*
I belong to a terrific organization that brings together C-level executives, once a month, to discuss issues each of us face. It’s called Vistage. One of the subjects we talked about yesterday was health care. It was like a focus group made up of seasoned, senior executives from many different industries.
The discussion revealed the tremendous divide between what ordinary Americans think about health care and what policy makers in Washington are doing. It’s a combination that is almost certain to ensure that whatever reform passes may make our problems worse, rather than better.
At the meeting were about 30 executives, representing everything from financial services, commercial real estate, manufacturing, high technology, pharmaceuticals, insurance, retail, non-profits, travel and others. Although all thought health care costs were in a state of crisis in America, I did not hear anyone say this was the case in their business. To be sure, some complained that health costs were high, and that there were few alternatives available. But others described changes they had made to their plan designs that had actually reduced their corporate health expenses.
We talked about the proper role of government, the comparative worth of systems in other countries, the responsibility of people to take care of their own health, end-of-life care, over-treatment, the uninsured, access to care, comparative effectiveness, and our own expectations of what the system should do for all of us. There was no consensus among this group of 30 business leaders as to these subjects and what we should do about them, other than that they are important topics that we need to address. I suspect this is true outside of this group, too. Indeed, the huge collection of issues that fall under the category of health care reform is something I’ve pointed out before.
But the President and leaders in Congress want debate on health care to end. They want a a bill to pass in the next couple of weeks.
Most of the group members were surprised to hear that Congress had already drafted legislation and was getting ready to vote on it.
It’s a remarkable thing. We are in the midst of trying to redesign the largest health care system in the world, and we’re barely debating the merits of it. How many members of Congress will have read the 1,1018-page bill once they vote on it? How many Americans will understand what implications it has for their health care if it — or something like it — becomes law?
The President often says that the status quo in health care is “not an option.” The trouble is, the status quo in health care is a rapidly changing thing. Today, every day, employers and doctors and so many others are busy making real, meaningful changes to our health care system. Not by waiting for committees of Congress to pass legislation, but by getting together and doing things that improve the quality and cost of care and the lives of patients. We need to be listening to their stories, and learning from them. Congress hasn’t done this, and can’t now.
There is an opportunity to build a real consensus around the important issues we talked about yesterday. We can transform our health care system in ways that make all of us proud. But it can only happen by working through these hard questions, not by hurrying to pass a bill before the August recess. Those who say we have a once in a generation chance to reform health care today may be right, but not for the reasons they think. By passing bills without consensus on this deeply important and emotional issue, they are ensuring that no one will really want to try to reform health care again for a very long time.
Which leaves us very much where we started. I will continue to do my part to share the important stories of how real people are making real reform. The political attention to reform may end sometime this year, but the reality of people trying to figure out what to do when sick will continue.
*This blog post was originally published at See First Blog*