OPPE, FPPE, MOC, MOL .... Slurping the alphabet soup of physician assessment

A couple of months ago I drove past fertile vineyards and took in the not-so-sweet scent of dairy farms, en route to a small community hospital in California's Central Valley. I had been invited to present a continuing medical education session on The Joint Commission's requirements for clinician evaluation.

As a board-certified practicing pediatrician, I am all too familiar with my own relatively new requirements for re-certification. The American Board of Medical Specialties recently introduced a Maintenance of Certification (MOC) process much more extensive than what was required in the past. I now need to pass a periodic closed book examination, demonstrate ongoing learning and participate in quality improvement projects.

The Joint Commission has its own set of evolving acronyms, OPPE and FPPE, designed to provide oversight for clinicians applying for or maintaining hospital privileges. In 2010, the Federation of State Medical Boards' Maintenance of Licensure (MOL) process specified that physicians demonstrate continuous professional development in order to renew their medical license.

I am all for greater oversight. Who would want sub-standard care for their patients, let alone for them, their friends and family members.

In an ideal world, this system of monitoring would produce better and safer care and not be significantly burdensome to hospitals or clinicians. However, the current state of clinician evaluation may at best be inadequate and at worst be detrimental to actual value and quality improvements.

There are a number of issues with our current ways of evaluating clinicians. Evidence supporting the effectiveness of MOC in improving clinical practice and patient-level outcomes is starting to trickle in, but is far from conclusive.

Multisource feedback (input from peers and patients) has its own set of limitations in assessing a clinician's ability to practice medicine. Studies advise exercising caution when using peer and patient feedback since it may be subject to biases. For example, physician assessments are frequently influenced by personal characteristics, rather than by professional performance.

Providing patients reassurance that the clinician or hospital treating them follows certain standards is a worthwhile goal. However, making sure that these plethora of requirements really translate to better, safer and more cost-effective care is an even more worthwhile one.

- Ulfat Shaikh

Checklist ... check.



Checklists have been criticized as  ‘dumbing down' medicine. However, the evidence that they can save lives is mounting.

A new study earlier this year in the New England Journal of Medicine showed that checklists on-hand could help doctors and nurses manage emergencies in the operating room. These include high-complexity and high-stress situations, such as when a person's heart stops beating or a patient begins bleeding uncontrollably.

  

In the study, teams that used crisis checklists had three quarters lower likelihood of missing crucial steps when complications occurred in the emergency room.

 

Atul Gawande, also the author of the Checklist Manifesto, had 17 operating room teams go through 106 simulated surgical emergencies, with or without checklists. With checklists, the proportion of critical actions missed during emergencies dropped from 23 percent to six percent. Almost all clinicians who participated in these simulations reported  they would want a checklist if a crisis occurred during surgery.

Previous research by Gawande's team demonstrated that using pre-surgical checklists helped reduce the risk of surgical complications. Such checklists are now standard procedure in many operating rooms across the US.

Checklists have been used for years in military and aviation, along with other techniques such as cross-monitoring, feedback, check-back, call-out, SBAR (situation, background, assessment, recommendations) and team training that have been introduced relatively recently into the world of medicine.

The case for techniques to improve team communication (such as check-backs) and standardization of practice (such as checklists) was brought home to me last month as I returned from the TeamSTEPPS Master Trainer course at ISIS, the University of Washington's Institute for Simulation and Interprofessional Studies. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) was designed by the Department of Defense and the Agency for Healthcare Research and Quality to integrate teamwork into practice and to improve the quality, safety, and efficiency of health care.

Buckling myself into my seat on the airplane on my way home from Seattle, I felt a sense of heightened awareness as I started to notice flight crew announcements that I had previously just tuned out. As my airplane prepared to push back, I heard the announcement, “flight attendants, arm doors and cross-check". With my TEAMStepps training fresh on my mind, I had a feeling of déjà vu when the flight attendant replied, "doors armed and cross-checked". I suddenly felt much safer.

- Ulfat Shaikh

The chicken or the egg: do electronic health records reduce malpractice claims?

Electronic health records (EHRs ) have been touted by believers to be the cure to all clinical evils. They promise to improve communication between clinicians, increase the efficiency of visits, reduce costs, prevent medication errors, increase care coordination, and do everything short of taking your dog for a walk.

Beginning in 2011, the U.S. government initiated financial incentives to hospitals to promote EHR adoption.

Skeptics bring up the concern that EHRs can make clinicians more likely to commit errors due to poorly designed software, unfamiliarity with new systems, or the hazards of the infamous copy and paste function.

Contrary to these concerns, a Massachusetts study found that physicians who use EHRs may have a lower rate of malpractice claims than those who don't. The researchers surveyed 275 physicians to assess their use of EHRs as well as the number of lawsuits filed against them. Malpractice claims for physicians who used EHRs were a sixth of those for physicians who did not use EHRs. Using an EHR was associated with an 84 percent lower chance of getting sued.

This leads to the question of the chicken or the egg. Are physicians who are late adopters of EHRs have particular practice patterns or characteristics that may make them more likely to be sued?

An article in Health Affairs found that physicians in non-primary care specialties and smaller practices, as well as those over 55 years of age lagged in adopting EHRs. Other studies support this finding and have identified physician characteristics associated with early adoption of EHRs. Younger physicians, those working in group and single-specialty practices, and those providing more preventive and chronic disease management services are more likely to adopt EHRs earlier.

- Ulfat Shaikh

OpenNotes and the demise of doctor-speak

A recent study shows that allowing patients easy access to read their doctor's notes can transform the doctor-patient relationship and result in high quality patient care.

Over one year, 105 physicians allowed more than 19,000 patients in Boston, rural Pennsylvania and Seattle electronic access to their medical office visit notes. Initial worries about this unconventional practice were unfounded. Patients reported that they more accurately remembered what was discussed during visits and felt more in control of their health care.

Not only this, OpenNotes also improve patient outcomes. More than half the patients reported a year later that they were more likely to take their medications as prescribed.

Not too surprisingly, almost all patients wanted continued access to their visit notes after the study ended. More unexpectedly - all doctor's in the study chose to continue sharing notes with patients. So all in all, a pretty resounding endorsement for openness and transparency in medical records.

However, one question in my mind remained. Did opening up medical notes to patients affect the infamous doctor-speak? This refers to the sometimes amusing, sometimes offensive, but surprisingly universal form of communication invented, propagated and used by clinicians all over the world. And did it reduce doctor's use of medical terminology, a whole new language by itself. To give you an idea of the magnitude of medical vocabulary the average doctor-in-training needs to pick up - Stedman's Medical Dictionary has definitions for more than 107,000 terms, is 2100 pages long, and weights about the same as a small baby.

For instance, will a patient be offended if he reads in his medical records: 20-year-old male, SOB resolved, FU if recurs (in case you were wondering - shortness of breath and follow-up). Or is it in bad taste to note that someone has pea soup stool, coffee ground vomit, coca-cola colored urine, or ripe cheese odor?

Will a patient understand that a "negative" chest X-ray is actually a much more desirable thing to have than a "positive" one?

And then there is the whole other ethical issue surrounding medical slang. Turns out that some clinicians have made a hobby of this. Dr. Adam Fox, who has a day job as an allergy specialist in the UK, is a published medical slang expert. He spent 5 years rounding up a list of more than 200 medical terms, some of which seriously need be retired. The list includes FLK (Funny Looking Kid), GLM (Good Looking Mum), TEETH (Tried Everything Else, Try Homeopathy), and GOK (God Only Knows).

Less colorful doctor-speak can have issues too. A Canadian study showed that the more medical-sounding the term, the greater the scare-factor. Seborrheic dermatitis was perceived by the college students they surveyed as deadlier than dandruff, and androgenic alopecia was considered more serious than male pattern baldness.

So is doctor-speak a potentially extinct language?

A recent study that looked at the content of visit notes in a group practice in Minnesota found no change in the kinds of notes that doctors wrote after patients were given online access to their visit records. The researchers of OpenNotes had a slightly different experience. A few doctors in their study reported that they had changed how they composed their notes. Some said that they now wrote "better notes" and learnt "better documentation - a good thing."

Dr. Fox's compendium of medical slang may soon be of historical interest. I for one, will not be dejected to see this particular medical invention phase out.

- Ulfat Shaikh

Food for thought at ISQua, Geneva

Got back last week from the International Society for Quality in Health Care's 29th International Conference in Geneva. I was there to present a paper on our experience with using clinical decision support tools in electronic health records to help children maintain healthy weights. 

Over 1200 people from 66 countries attended the meeting. A personal highlight for me was listening to Margaret Chan, Director General of the World Health Organization (WHO) speaking at the opening plenary. The magnitude of her stature in the world of global health is inversely proportional to her actual height. In fact, she began her talk by peeking up from behing the podium and asking, "can you see me".

I learnt from Chan that health care faces a shortage of 4 million clinicians. Referring to the "young discipline" of patient safety, she said that unsafe injections alone result in 1.3 million deaths worldwide, costing $535 million in direct medical costs, and an astounding loss of 26 million years of life.

While most teenage girls in my day dreamt about scrunchies, clothes with shoulder pads or the latest George Michael audio cassette tape, my dream was to visit the WHO. Yes, I know ... I was quite a serious kid.

This aspiration finally came true. The conference offered a site visit to the WHO where staffers presented highlights of some of their programs. One eye opening fact that sunk in after the site visit was the evolving reality of global public health funding. For instance, did you know that if the Gates Foundation were a country, it would be the 3rd largest funder of the WHO?

Another stark fact is that political will is a key driver in solving our pressing global health problem. For example, polio was eradicated in India last year - an undertaking previously thought by many to be impossible. But top down state and national government support showed the world that it could be done. Now we are left with just 3 countries where polio remains endemic - Pakistan, Afghanistan and Nigeria. Addressing security concerns to enable health workers deliver vaccinations has been a continuing challenge in these countries.

The terrifying part is that all of our work could be shattered in an instant by complacency. Last year we saw ongoing polio outbreaks in several countries due to international travel. Our vulnerability is evident by modeling that shows that failure to eradicate polio could cause a worldwide resurgence of polio within 10 years.

Perhaps the most significant thing I realized at the meeting was that (in Margaret Chan's words) "solutions don’t need to break the bank". For example a quality improvement intervention to prevent central line associated blood stream infections in Michigan, supported by a $450,000 grant from the Agency for Healthcare Research and Quality, saved 1,500 lives and $100 million annually across the State of Michigan. Peter Pronovost, the researcher from Johns Hopkins who led this study, as well as Carolyn Clancy, the Director of the Agency for Healthcare Research and Quality, a funder of this study, reinforced this point during their respective keynote presentations.

All in all an amazing learning and networking experience. I left the conference with a happy and energized buzz. Perhaps 4 days of espresso and chocolate had something to do with it too.

- Ulfat Shaikh

Margaret Chan, Director-General of the WHO, speaking at ISQua

 

If banks and airplanes were like health care (and other scary thoughts)

If you think that the bills you receive from your doctor or hospital seem obscenely large and confusing, you are not alone.

The latest report from the Institute of Medicine, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, highlights the cost of waste in the American health care system. The report estimates that a staggering $750 billion a year in the U.S. in 2009 was wasteful spending. 

Here is what a breakdown of how this money is misspent:
$210 billion - unnecessary procedures and treatments
$190 billion - paperwork and unnecessary administrative costs
$130 billion - inefficiently delivered services
$75 billion   - fraud
$55 billion   - missed prevention opportunities

Essentially, about 30 cents of every health care dollar is squandered.

Not surprising when you consider that a physician receives about $50 for spending quality time with a patient with a headache explaining conservative management options. Spending just a few quick minutes with this patient and ordering a brain MRI (which costs about $1500 and increases the patient's risk of cancer) makes this physician about the same amount of money, and depending on which circles he or she hangs out in, "helps one stay out of trouble".

So what are the implications of this report? A lot of attention in the health care reform debate has focused on rationing of services. This report offers some solutions about opportunities to cut costs without rationing.

The report discusses multiple provisions of the health law that could help bend the cost curve. Some of these include health information technology adoption, payment incentives rewarding outcomes instead of volume, team-based care coordination, patient portals to help patients and families share decision-making, and operations management to improve patient flow and increase efficiency.

The report tersely captures what would happen if other industries operated like health care currently does.

"If banking were like health care, automated teller machine (ATM) transactions would take not seconds but perhaps days or longer as a result of unavailable or misplaced records. If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination. If shopping were like health care, product prices would not be posted, and the price charged would vary widely within the same store, depending on the source of payment. If automobile manufacturing were like health care, warranties for cars that require manufacturers to pay for defects would not exist. As a result, few factories would seek to monitor and improve production line performance and product quality. If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not to perform one at all".

 - Ulfat Shaikh 

What is your Escape Fire?

More than 50 schools and universities recently hosted a free screening of the feature length film, 'Escape Fire: The Fight to Rescue American Healthcare'. The film premieres nationwide on October 5, 2012. This is a documentary by filmmakers Heineman and Froemke looking at the current state of America's $2.7 trillion health care system.

 

The University of California Davis Student Interest Group in Health Care Quality hosted a screening of the film last week. In the audience were students in medicine, nursing and business, as well as faculty and staff.

The name of the film draws inspiration from Don Berwick's book- Escape Fire. The film opens with Berwick talking about the Mann Gulch wildfire of 1949. The firefighter, Wag Dodge, lights an escape fire - intentionally igniting grass around him. This basically eliminates all surrounding flammable vegetation, thereby saving his life. 

 

Berwick and the filmmakers argue that we need similar unconventional and drastic solutions to change America's health care system.

 

Some things from the film that stood out.

• A startling statistic. The US spends $300 billion a year on medications - approximately as much as the rest of the world combined.
• The critical point that we do not have a health care system. We have a disease care system.
• Universal health care coverage is not the answer. Even with universal coverage, the health care system would continue spiraling out of control. The film proposes issues and solutions that need to be a part of the dialog on health care.
• The story of a war veteran on dozens of painkillers at a time, who was ultimately treated with acupuncture, meditation and yoga at Walter Reed Army Medical Center.
• 75 percent of health care costs are related to preventable diseases. A patient with repeated heart attacks and the significant social and environmental challenges he faces in changing his lifestyle.
• Fee-for-service incentivizes physicians to see as many patients as they possibly can. A well-meaning but frustrated physician fights a losing battle against mounting pressures to increase her "productivity".
• An employee wellness program at Safeway Corporation that motivates its workers to exercise and eat better with some very impressive results, in the process reducing the company's health care costs.
• Auto insurance rates are tied to driving history. The concept of health insurance rates being tied to healthy lifestyle so that lifestyle improvements drive premiums.

 

At the end of the screening, the filmmakers ask the audience to identify their own escape fire. My escape fire is focusing more on system-level improvements in patient care, with the goal of larger scale improvements in patient health outcomes. 

What is your Escape Fire?
 

- Ulfat Shaikh, with Wendy Nugent.
 

(Wendy Nugent has been a nurse at UC Davis for 26 years. She recently retired from her position as Assistant Director of Hospital and Clinics)