Apr 28, 2012

Not documented, not done. Really?

It is important to find ways to accurately understand what occurs during medical care. Reviews of medical records and patient surveys are commonly used as proxies for actually being inside an exam room and observing the visit.

But before we use these methods to figure out what happens during a patient visit, we first need to make sure that what we measure reflects what actually happened.

Counseling for nutrition and physical activity for children is a quality measure in the Healthcare Effectiveness Data and Information Set, a widely used set of performance measures in the managed care industry. Such counseling also is a criterion for “meaningful use” of electronic health records under the American Recovery and Reinvestment Act

My colleagues and I published a study last month that found the parental report via the use of a questionnaire administered immediately following their child's visit is a more valid method of assessing physician counseling on weight, nutrition and physical activity in primary care, compared to medical record documentation.

We audio-taped about 200 primary care visits and asked parents to fill out a questionnaires right after the visit to ask them what was discussed. We also reviewed electronic health records for these visits. The study suggests that electronic health record documentation may significantly underestimate the counseling that patients receive. What goes into electronic medical records may also vary depending upon nuances in electronic health record tools and templates used by physicians.

- Ulfat Shaikh

Apr 20, 2012

Choosing Wisely

The U.S. spent $2.6 trillion on medical care in 2010. Despite spending much more on medical care than any other developed country, American medical care has mediocre clinical outcomes.

Open discussions between patients and their clinicians about tests and procedures can facilitate the delivery of the right care at the right time. As a pediatrician, I often see parents who come into my clinic with names of tests or procedures for their child that they have read or heard about. More frequently than not, these parents, when engaged in discussions on evidence-based recommendations, make decisions about their child's care that are reasonable, objective, and surprisingly more conservative than one might intuitively expect.

Earlier this month, nine medical societies in the U.S., representing 375,000 physicians released a 45-item list of commonly used procedures that they no longer recommend we automatically order. A major goal of these recommendations is to reduce wasteful spending without harming patients, as well as to prevent adverse effects of overuse, such as radiation exposure.

The list includes reconsidering the routine use of a number of tests and procedures. Among them, annual EKGs for low-risk patients with no heart symptoms, repeat colonoscopies within 10 years of the first, chest X-rays before outpatient surgery, early imaging for back pain, CT or MRI scans for in patients who faint but did not have seizures, antibiotics for chronic sinusitis, osteoporosis screening using DEXA scans in younger patients, and cardiac stress tests for patients without coronary symptoms.

These recommendations provide a springboard for engaging clinicians and patients in discussions about wisely choosing diagnostic and treatment options.

Click here to read more about these recommendations.

- Ulfat Shaikh

Apr 16, 2012

Team spirit in health care

Robust interprofessional collaboration results in higher quality and safer care for our patients and improves health outcomes.

National organizations have recently focused on the imperative for interprofessional collaboration. In 2010, the Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, offered recommendations that focused on improving health care through contributions from nurses. A key recommendation calls for nurses, physicians and other healthcare professionals to partner with each other in redesigning our health care system.

Developed by the Department of Defense and the Agency for Healthcare Research and Quality, the evidence-based program, TeamSTEPPS, helps optimize patient care by improving communication among healthcare professionals.

The Patient Protection and Affordable Care Act has a strong focus on engaging interprofessional teams to improve the quality, safety, and efficiency of health care.

There are multiple challenges to interprofessional collaborations, such as culture, job experience, and unclear roles and responsibilities. These challenges may create frustration among team members. Poor understanding of roles and responsibilities may potentially undermine respect for the unique contributions of our colleagues. Health care professionals need to practice patience and humility and remind each other that we are playing on the same team.

Our common goal is to deliver the best care possible to our patients. This is not an easy job. So, at the end of the day, as we work together and support each other, we can collectively overcome challenges associated with our health care system.

Also, don’t forget to celebrate success and express appreciation whenever possible.  It can make a world of difference for our patients and their families!

See an introductory video about the TeamSTEPPS program below:

- Ren Bee, with Ulfat Shaikh
(Ren has been a nurse for the past 11 years and just received a master's degree in nursing from UC Davis)

Apr 5, 2012

Partnership for Patients turns one

In 1999, the Institute of Medicine's study, “To Err is Human,” estimated that up to 98,000 Americans die each year from preventable medical errors. An average of 1 in 3 patients suffer a medical error or adverse event during hospital care.

A year ago, in April 2011, the Department of Health and Human Services launched the Partnership for Patients. The Partnership brings together hospital leaders, employers, health care providers, patient advocates, and state and federal governments toward the achievement of common goals of better care and lower costs. More than 7000 hospitals, physicians, nurses, health plans, consumer groups, and employers nationwide have since pledged their commitment to this initiative.

Up to a billion dollars of federal funding from Affordable Care Act has been committed towards 2 initial goals over next 3 years: Reducing preventable injuries in hospitals by 40% and reducing hospital readmissions by 20%.

Nearly $250 million was awarded to 26 state, regional, national, or hospital system organizations to be Hospital Engagement Networks. Hospital Engagement Networks will help identify successful strategies and enable their dissemination to hospitals and health care providers. Hospitals across the country are being provided with resources, financial support and networking to help them adopt best practices and to adapt them to their local circumstances. The formation of learning collaboratives, a concept successfully implemented world-wide by the Massachusetts-based Institute for Healthcare Improvement, is part of this strategy.

The Partnership could save 63,000 lives and up to $35 billion in health care costs over the next three years by preventing hospital-related injuries.

Here is a video, featuring patient advocate Sorrel King, that describes this initiative.

You can't manage what you can't measure. I believe that one of the strongest aspects of the Partnership is the establishment and implementation of a system to track and monitor progress in meeting national measurable quality improvement goals. This is a culture shift for many clinicians. Getting used to regular performance feedback and assuming individual responsibility to continually identify and implement strategies to better care for patients is now part of the job description for all clinicians. 

- Ulfat Shaikh

Apr 1, 2012

"Hot spotting" in healthcare

The United States spends about $2.5 trillion on health care annually. Health care spending is highly concentrated... just 5% of the population accounts for almost