It’s Not About The Box Improving Care at Group Health with People, Process and Technology

April 30, 2012

Don Berwick presenting the Birnbaum Lecture

Filed under: Policy — Matt Handley @ 9:25 am

A great way to start a week in spring – Don Berwick is presenting at the Birnbaum lecture at the Convention center in Seattle.  Really looking forward to Don’s talk – take one of the foremost innovators in Health care and season him with time leading CMS, and you get a remarkable perspective.  Don has inspired me for years – I have had the opportunity to learn from him in many ways over many years, including having him shadow me in clinic.  His introduction includes many honorifics, including Knight Commander of the Most Excellent Order of the British Empire. Love that one.

To save notification Emails for those subscribed I will blog happily along and then just post the piece rather than live-blog the event.  ITs a great story, so a long post.

One of my favorite mantras is “No stories without data, and no data without stories” – and Don is the master of storytelling with data.  Today’s talk (not transcribed – but a good faith effort to relate the story):

Midway through residency in 1974 in a NICU rotation, he is awakened at 3 AM to perform an exchange transfusion (a procedure no longer necessary thanks to Rh testing) for a small baby, call her “Baby Gray”.  A sleepy resident, a lot of tubes and stopcocks and a bag of O neg blood.  Basically, in an exchange transfusion blood is taken out of the baby’s umbilical vein, a stopcock is turned and the blood is thrown away, the stopcock is turned and blood is taken out of the O neg bag, the stopcock is turned again and the blood is pushed into the umbilical vein of the baby.  Repeat this many, many times, to basically change out the baby’s blood cells and serum (which contains Mom’s antibodies).  But something went wrong that night.  It was hard to push the blood into the baby, and the baby didn’t look well.  Both the baby and our pediatric resident are tachycardic.  Don stops the process, called for lab tests and help.  A neonatology resident came in as the blood test came back.  The baby has a hematocrit of 90 (normal about 35 – 40).  Crisis.

The hospital where Don has done the procedure before delivered whole blood in one bag.  A different blood bank supplying the hospital where Baby Gray is used a different strategy for delivering the blood.  The red cells were separated from the plasma and red blood cells and plasma were delivered in two different bags.  Don had been using red blood cells without the plasma for the exchange transfusion.  Don sees the clear bag with the plasma dangling below and recognizes that he has been part of an error that has put the baby’s life at risk.  The neonatology resident saved the day (after some complication the baby does well) and reassured Don that this could have happened to anyone.

Don responded as most all of us would have (especially then).  He did not come forward and talk about the error so that it could prevent other patients and doctors from the same error and harm.  Don did nothing.  He carried the pain privately.  His internal dialogue has not kind. “How could I have done anything so stupid”.

Our knowledge of safety and error are now pretty good.  One of the first books about safety, “Human Error” by James Reason may be the best of its kind – the source of the “Swiss cheese model” – laying out the idea that latent causes of error (sleepy resident, non-standardized blood bank procedures, etc) happen to line up like holes in Swiss cheese.  Safety science has enabled us to build safer systems, including more just cultures.

Shift frames – Don Berwick as the self-described amateur ethicist.  Surely it is unethical to allow any other baby to be injured.   It is more than the error itself, it is in the silence that follows.  The silence that makes it so that the error is still possible for other patients, and that keeps the error from the family.  We are now all aligned around safety, just culture, disclosure and quality.

The ethical answers to this case scale to the question of our health system.  The fist locus is that the ethics of quality lie in the professionals that practice medicine.  The second locus of the ethics of quality is leaders.  Imagine that the next day, wracked by guilt, Don brings the cause to leaders so that things can be made safer.  “You are not a superhero, and you can make mistakes – but the well being of your patients and of other patients depends on your sharing what goes wrong so that we can build stronger systems of support to minimize the errors humans make”.

There is an inescapable connection between the ethics and actions of individuals and leaders.

Segue (the one that Don’s wife believes is hard to follow)

There are many dimensions of quality that we know well – safety, effectiveness, patient centeredness, timeliness, efficiency and equity.   And some of these stories, especially safety, are compelling.  The story about the baby and the exchange transfusion “has us at hello” – heartstrings are tugged, and we feel for both the patient and for the caregiver.

But we can and need to expand the ethical call beyond just safety and effective care, to all of our quality goals.  Now the particular aim that needs to be driving us is Efficiency – the issue of cost.  We need to grapple with the premise that we have an ethical duty to address cost, for the sake of individuals and for society.  Our ability to do everything else that government might do for good is hanging in the balance.  We will not be able to fund schools or maintain support for the disadvantaged unless we address the costs of our health care system.  And we know that this burden is not necessary if we cease our concessions to waste.

We can use an analogy to environmental models (Dons’ recent article in JAMA) where no single strategy can fix our carbon problem, but many different strategies (“wedges” like solar power, more efficient cars, carbon sequestration, etc) can work together to get enough reduction to prevent catastrophic global warming.   In health care, there are 6 wedges of waste:

  • Overtreatment
  • Failures to coordinate care
  • Failures in care delivery
  • Excess administrative costs, excessive health care prices
  • Fraud and abuse.

The minimum estimates of the sum of health care spending for these categories is 21% of all health care spending, the median is 34% and the highest estimate is 47%.  Scary as those estimates are they should bring us hope – if we tackle waste we can continue to provide all the care we should and save considerable resources.  Over 9 years we are looking at $11,000,000,000.  There is a “T” involved in that number.

At the individual level, it is easy to see that the next “Baby Gray” will die unless leaders in health care accept their accountability to learn from error.  We are well down the road to making care safer, but the analogy to affordability has not achieved engagement.

The harm from the health care system on our society will not cease unless the leaders accept their responsibility for the waste in our system.  It is easy to see that while there are a set of excuses for all of the wastes, the analogy to safety is inescapable.

Health care leaders need to assume the responsibility without excuses to tackle waste.

Harm to an individual patient by medical error is different than the harm from waste.  With waste, you can’t name who is hurt.  No one wasteful act harms an individual.  But waste is theft and theft is wrong.  Waste threatens healthcare as a human right.

Don’s Principles for a Framework for action.

  • Put the patient first
  • Protect the disadvantaged
  • Start at Scale
  • Return the money
  • Act Locally

One step further to an ethics of improvement

  • Professionals have an duty to help improve the systems in which they work
  • Leaders have a duty to make #1 logical, feasible, and supported
  • No excuses for inaction on #1 and #2 are ethically acceptable.
  • The duty to improve across all five, and that includes waste
  • Those who educate professionals have a duty to prepare them for this important work

There is a lot of anguish over how we can get things on track – the public is looking for sanity to come out of this.  While politics and policy matter, they are insufficient to fix this.  It will necessarily fall to those who provide care, and those who make it possible for them to provide great care, to lead change to reduce waste and improve value.

Hard to listen to Don and not run out of the room and take action.  I know that my meetings later today will some different focus.

September 14, 2010

EHR Mythology

Filed under: Electronic Chart,Epic,MyGroupHealth,Policy,Quality / Affordability — Matt Handley @ 7:28 am

Just a link to a simple post that makes a lot of cogent points about EHRs, dispelling much of the misinformation out there:

EHR Mythology 101

The paragraph about why EHR implementations sometimes fail has one important omission – I believe the “group-ness” is the most important predictor for success in most any venture a medical group/delivery system undertakes.   Reading it I realize how simple  my job is compared to others – we have a great medical group that keeps the patient at the center and works to transform care.

September 9, 2010

“Lessons from the Mammography Wars”

Filed under: Evidence Based Medicine,Policy,Population management — Matt Handley @ 10:27 am

A provocative piece in the weeks NEJM that uses the recent dust up about mammography (link to the article) as a case in point has two main themes, one of which is a favorite of mine:

1.  The idea that benefit is mostly determined by baseline risk, rather than relative risk reduction

“the net benefit of all medical treatments is a continuous function of three factors: the risk of morbidity or mortality if untreated (RiskNoRx), the treatment’s relative risk reduction (RRRRx), and the treatment’s risk of harm (HarmsRx):

Net Benefit = (RiskNoRx×RRRRx) – (HarmsRx).

As the risk of no treatment (RiskNoRx) decreases, the net benefit of treatment will decrease, even if the treatment’s relative benefit (RRRRx) remains constant. Indeed, for many interventions, if the risk of no treatment is low enough (e.g., if we lower the threshold for treatment too far or if a patient’s life expectancy is relatively limited for other reasons), then the side effects and risks of treatment will dominate, and the treatment will result in net harm.7-9 Since the risk of no treatment varies dramatically among patients for almost every disease or condition, even a highly effective intervention will show a gradient of net benefit in a given population.”

2.  The provocative  idea that specialty societies and other vested interests may have important conflicts of interest that impact their recommendations:

“In any other industry, we accept the idea as natural that those providing a service or product hold their own and their shareholders’ interests as a primary objective. Why have we failed to acknowledge that the same phenomenon occurs in health care? Although it is true that individual medical providers care deeply about their patients, the guild of health care professionals — including their specialty societies — has a primary responsibility to promote its members’ interests. Now, self-interest is not in itself a bad thing; indeed, it is a force for productivity and efficiency in a well-functioning market. But it is a fool’s dream to expect the guild of any service industry to harness its self-interest and to act according to beneficence alone — to compete on true value when the opportunity to inflate perceived value is readily available.”

I am not sure of the feasibility of the recommendations the authors advance for how to disentangle the impact on health outcomes in absolute terms from the values we assign those differences.  Would love to hear from others about how they see this.

July 27, 2010

Meaningful Use

Filed under: MyGroupHealth,Policy,Secure Messaging — Matt Handley @ 8:28 am

The Meaningful Use rules are now finalized – organizations can get past the lobbying and onto the work of making sure that their investments in technology make a difference for how we deliver healthcare.  It is a welcome change from resistance to action.  The final rules seem to most a pragmatic compromise, balancing engagement (not setting the bar too high) with achieving something that is – well – meaningful (not setting the bar too low).  It has something for most everyone, and is more like a fun run than a marathon.  Organizations that are committed to transformation on behalf of patients will find that while there is work to be done, it is do-able.

There are a host of summaries on the web – my two favorites:

David Blumenthal’s recent NEJM article

A summary from Robin Raiford

Pragmatism is a fine organizing principle, and might be just the right thing for the stage in development where our chaotic national health care “system” is – where most care is delivered through small offices and the hurdles to organizing care delivery are huge.  But in addition to pragmatism, we need a little inspiration – something to suggest that there is a rational future state that is more oriented towards what patients desire and benefit from than an incremental improvement in the chaos.  We argue for that in an April Health Affairs article about meaningful use .  The meaningful Use rules lack a patient voice, and are relatively timid about providing meaningful electronic access and access to their records and their doctors (and health care teams).   Our experience with patient centered HIT has demonstrated what is possible in the special setting of aligned financing and care delivery.  I am convinced that with strong leadership, and several of the provisions of health reform that allow experiments with payment reform, these things are possible to a far larger number of groups than was true in the past.

The blueprint isn’t that complicated, but getting there requires considerable changes in perspective for most groups.  Leveraging technology to improve outcomes for patients requires that we do two important things:

1. Keep the patient at the center
2. Think simultaneously about people, process and technology

Simple rules that allow innovations of all kinds.  We are looking forward to the challenge.

March 26, 2010

EBM triumphs

Filed under: Policy — Matt Handley @ 10:27 am

Thanks to Kathy Brown, Director of GHC Pharmacy for sending along this information:

Today Kaiser Permanente won a lawsuit they brought against the maker of Neurontin (gabapentin).  This is the result of a long standing case that Kaiser had against Pfizer for their pattern of off label marketing of Neurontin…approved in 1994 for add-on tx of partial seizures….it bloomed into $10Billion drug mostly for the off-label use for migraines, bipolar and pain management.
The pattern of off-label marketing was company strategy including ghost written articles, suppression of negative studies and millions spent in getting physicians to prescribe neurontin for migraine, pain and bipolar disease.      Of note, of the many company documents and emails introduced as evidence, there was an email about Group Health and a residency project to reduce the use of neurontin based on the lack of evidence of efficacy–the email stated that “all we need is for Group Health to present data at AMCP to induce a snow ball effect”  Indeed, GH was amongst the first to look at limiting use of this drug for lack of evidence (something to be proud of!).

…and part of the closing arguments:  “The premise of evidence-based medicine is that there is a complete, accurate, and truthful scientific base to it.  Dr. Dickersin wrote in the New England Journal of Medicine, she said that “Selective outcome reporting,” cherry-picking the results, “threatens the validity of the evidence.” The heart of evidence-based medicine is the evidence, but the soul of evidence-based medicine, the soul is the validity of that evidence. And when the validity of the evidence is corrupted by lies and misrepresentations, as was done in this case, then physicians can no longer trust and rely on the validity of the evidence. If your verdict is a verdict you return for the defendants in this case, it will embolden them to continue market-based medicine. And if market-based medicine continues, physicians won’t be able to trust and rely on the validity of the evidence, and evidence-based medicine, as we’ve come to know it today, will die. But if you return a verdict for Kaiser, your verdict will be for evidence based medicine.”

Jury verdict under federal RICO and California’s Unfair Competition Law:  $47 million, which will be automatically trebled — $141 million.

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