Transforming Primary Care!

[CC-Conrad Clyburn-MedForeSight]

Colleagues,

Over the last few weeks, I have had an opportunity to interact with providers and health information technology experts on the front line of deploying Electronic Health Records (EHR) into the U.S. healthcare system.  Fermenting with great velocity ... among providers, technology providers, payers and policy makers ... are an astounding number of ideas that fundamentally re-think traditional healthcare delivery ...

Please see from today's New York Times, some of the issues facing primary care physicians ... most compellingly articulated in Dr Richard J. Barons' recent New England Journal of Medicine article " “What’s Keeping Us So Busy in Primary Care?”...

... The article documents in stunning detail the “invisible” work that primary care practitioners must do in addition to seeing patients each day ...

... There are on average 17 e-mail messages to write, 14 consultation reports to review, 24 phone calls to field, 11 X-ray and imaging reports to read, 12 prescriptions to refill (not including those done during a visit or phone call) and 20 laboratory reports to be checked, all on top of the work involved in seeing a daily quota of at least 18 patients...

... With 30 to 40 million new patients coming into the U.S. system, new models of healthcare delivery will be required ...   

... For example, Dr. Baron’s group has developed a program that encourages continuing dialogue between providers and patients with diabetes, high blood pressure and elevated cholesterol, patients who make up nearly three-quarters of his small group’s practice...

We face both challenges and an opportunities  ...  Where do you stand?

... I think MedTech-IQ members will be part of the solution!


Read on at: http://www.nytimes.com/2010/05/13/health/13chen.html?src=mv&ref...


ENJOY!

CC

[John A. Liebert, MD]

There is total disconnect between decision makers imposing system changes and purchasing IT to transform health care. For example, sickness is not like banking or engineering; it is 24/7. Many patients enter the system for their first clinical encounter on weekends and after hours; there is an expectation that full medical services are available. A region is lucky to have one or two Neurosurgeons and a hand full of Orthopedic Surgeons; the Medical Director of a large system in Arizona told me, "I don't want to be the last hospital in America with a call schedule."

This is just one example of scores of issues totally ignored in contemporary debate about health care. Another is the failure to get system consituencies on board from the earliest design of EMRs and EHRs. When Boeing built the 757 they brought in customers to sit with engineers and computer developers to design the aircraft via CAD. Every arline had different needs; certainly, there had to be a general structure, as there has to be with EHR and EMR development. But, dashboard design pays little attention to what doctors and nurses actually have to do to be both effective and stay out of high risk decision-making. Similarly, Pharmacy, Accounting, Security etc. I published an article on this in the King County Medical Society Bulletin a few years ago; it was called Unity in Health Care. Ironically, it responded to testimonials of hospitals changing their delivery systems The Toyota Way. (I don't think that name is applied now, but Lean Engineering and Lean Management, synonymous with Toyota Way, are still used.) Again, I worked in a system like that and was scheduled to work the Thanksgiving weekend. That is about 80 straight hours, prohibited for residents in training, but not other MDs. The FMGs on Green Cards have little choice but to do it and hope they don't die. Temporary docs, like I, can pick and choose, and there are some tough and hungry ones who want that 24/7 work to pick up overtime. There are not enough of them, however, to drive this big bus coming at us. And, Mr Orszag sees the solution for matching severity and complexity of presenting illness to credentials; in the military, the ER doc calls specialists directly - at least in my experience they did. So, the military has not been able to implement such matching, and they have the authority to do so. How does Mr Orszag plan to match Severity and Complexity of presentation with level of training and expertise - i.e. sore toe with PA; acute gout with Internist; foot fracture with Orthopedist? (The last, just to be awake for your hip operation at 0700, now charge $1k per night to carry a beeper!) No more straight 70 hour shifts for docs coming on board today - compensation is not promising enough, and there is too much sleep medicine literature showing how their retirements may not be healthy - if at all - under current on-call requirements. John Liebert, MD

[John A. Liebert, MD]

Not just Primary Care; of interest would be a study to determine how EMRs either make this problem better or worse. Nurses spend a lot of time on the computer in hospitals that have EMRs. It is just assumed that such practice reduces errors; that is marketing, but not research driven testimonials. Have computers on the ward simply allowed researchers to find errors that have always occurred or are they distractions themselves? John Liebert, MD

Interrupting a Nurse Makes Medication Errors More Likely
In hospitals, mishaps increase along with distractions, study finds

HealthDay ON Apr 26, 2010 at 4:00PM
chime in now
MONDAY, April 26 (HealthDay News) -- Distracting an airline pilot during taxi, takeoff or landing could lead to a critical error. Apparently the same is true of nurses who prepare and administer medication to hospital patients.

A new study shows that interrupting nurses while they're tending to patients' medication needs increases the chances of error. As the number of distractions increases, so do the number of errors and the risk to patient safety.

"We found that the more interruptions a nurse received while administering a drug to a specific patient, the greater the risk of a serious error occurring," said the study's lead author, Johanna I. Westbrook, director of the Health Informatics Research and Evaluation Unit at the University of Sydney in Australia.

For instance, four interruptions in the course of a single drug administration doubled the likelihood that the patient would experience a major mishap, according to the study, reported in the April 26 issue of the Archives of Internal Medicine.

Experts say the study is the first to show a clear association between interruptions and medication errors.

It "lends important evidence to identifying the contributing factors and circumstances that can lead to a medication error," said Carol Keohane, program director for the Center of Excellence for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston.

"Patients and family members don't understand that it's dangerous to patient safety to interrupt nurses while they're working," added Linda Flynn, associate professor at the University of Maryland School of Nursing in Baltimore. "I have seen my own family members go out and interrupt the nurse when she's standing at a medication cart to ask for an extra towel or something [else] inappropriate."

Julie Kliger, who serves as program director of the Integrated Nurse Leadership Program at the University of California, San Francisco, said that administering medication has become so routine that everyone involved -- nurses, health-care workers, patients and families -- has become complacent.

"We need to reframe this in a new light, which is, it's an important, critical function," Kliger said. "We need to give it the respect that it is due because it is high volume, high risk and, if we don't do it right, there's patient harm and it costs money."

About one-third of harmful medication errors occur during medication administration, studies show. Prior to this study, though, there was little if any data on what role interruptions might play.

For the study, the researchers observed 98 nurses preparing and administering 4,271 medications to 720 patients at two Sydney teaching hospitals from September 2006 through March 2008. Using handheld computers, the observers recorded nursing procedures during medication administration, details of the medication administered and the number of interruptions experienced.

The computer software allowed data to be collected on multiple drugs and on multiple patients even as nurses moved between drug preparation and administration and among patients during a medication round.

Errors were classified as either "procedural failures," such as failing to read the medication label, or "clinical errors," such as giving the wrong drug or wrong dose.

Only one in five drug administrations (19.8 percent) was completely error-free, the study found.

Interruptions occurred during more than half (53.1 percent) of all administrations, and each interruption was associated with a 12.1 percent increase, on average, in procedural failures and a 12.7 percent increase in clinical errors.

Most errors (79.3 percent) were minor, having little or no impact on patients, according to the study. However, 115 errors (2.7 percent) were considered major errors, and all of them were clinical errors.

Failing to check a patient's identification against his or her medication chart and administering medication at the wrong time were the most common procedural and clinical glitches, respectively, the study reported.

In an accompanying editorial, Kliger described one potential remedy: A "protected hour" during which nurses would focus on medication administration without having to do such things as take phone calls or answer pages.

The idea, Kliger said, is based on the U.S. Federal Aviation Administration's "sterile cockpit" rule. That rule, according to the Aviation Safety Reporting System, prohibits non-essential activities and conversations with the flight crew during taxi, takeoff, landing and all flight operations below 10,000 feet, except when the safe operation of the aircraft is at stake.

Likewise, in nursing, not all interruptions are bad, Westbrook added.

"If you are being given a drug and you do not know what it is for, or you are uncertain about it, you should interrupt and question the nurse," she said.

More information

The Institute for Safe Medication Practices has more on safe medication use.

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