Healthcare Leadership Forum: Evidence, Support & Patient Safety

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Find in-depth coverage on
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The Healthcare Leadership Forum in Chicago focused on Evidence at the Center of Care with an impressive roster of thought leaders who discussed strategies for implementing evidence at the pointe of care, boosting interoperability and standards and smoothing care transition as well as  the significant need for further advances in patient safety.

“You could shoot holes in what we’re doing” related to evidence-based medicine (EBM) and quality assessment, said Carolyn M. Clancy, MD, former director of the Agency for Healthcare Research & Quality. 

“Ultimately, most people would like to provide the best possible care to their patients but how do you get this information out in a way that’s an easy, routine part of the day? Starbucks has more built-in error checking than most of medicine.” 

Unfortunately, developing measures of quality is difficult because there is a “choke hold around data capture. Evidence by itself doesn’t have that much meaning. We know that public reporting of quality performance is associated with improvements in care, but it’s not a silver bullet.”

‘Resolve the tension’

The 3,000 doctors at Beth Israel Deaconess Medical Center in Boston use a range of electronic tools to provide care, said CIO John D. Halamka, MD, MS. They use Meaningful Use standards to ship 5,000 summary records a day to a common repository where a third party normalizes the data. “We can then take the dataset and provide provider scorecards and feedback so they can understand how their practices are varying. We built a management structure that ensures they get this feedback because standardized work will increase quality and outcomes and lower costs.”

As co-chair of the national HIT standards committee, Halamka has been working to improve EHR use and interoperability via standards. “If we don’t resolve the tension, doctors are going to go nuts with popups that will cause such fatigue and offer no help.”

The clinical quality measures for MU Stages 1 and 2 are “extremely painful to collect and report,” he said. The U.S. doesn’t have a national healthcare identifier and “it’s highly unlikely that we will,” which is a big challenge, he said. The U.S. lacks uniform standards for ordering labs.

“We depend on vendors for cool new functionality but the companies’ agendas are so full. It’s highly unlikely there will be rapid, groundbreaking innovation.” 

Improving trials for useful evidence

EBM offers power and pitfalls to clinicians, said event co-chair Mark Roberts, MD, MPP, professor and chair of the department of health policy & management at the University of Pittsburgh Graduate School of Public Health.

Most evidence and guidelines are based on the latest randomized controlled trials which are not adequate to the complexity of the task at hand. Most large trials aim for FDA approval of a new drug which does not need to be better than what’s already available, just better than placebo. 

The studies are rarely designed to answer common clinical questions and, consequently, the guidelines built from these trials are less useful than possible.

“Homogeneity is not what you see in real-life practice,” Roberts said. “By its very nature, EBM is correct only on average in select populations.” 

EBM “breaks down a lot,” Roberts said. It became important because of the substantial variability in patient care. The problem, he said, is “our recommendations are blunt, and we need to develop methods for making them more personalized. We need to be able to estimate individual benefits and harms and we need to be able to predict the effect of therapies as a function of comorbidities.”

IT and predictive modeling may help tailor recommendations to individuals. “We need a paradigm shift in what we consider useful evidence. Most research is done in isolation but we need heterogeneity to be part of the reality.” 

The ‘next evolution of guidelines’

$25 billion is spent on IT in U.S. hospitals each year and “there has been a tremendous surge in the use of EMRs,” according to Howard C. Bauchner, MD, editor-in-chief of the Journal of the American Medical Association. Up to 70 percent of providers engage patients with EHRs but how rich and integrated those EHRs are is uncertain.

EBM has experienced substantial improvements, he said, such as incorporating systematic reviews into guidelines. The next evolution of guidelines and grading of evidence is beginning but “we still struggle in how to take that summary variable and understand how to articulate what that means from a clinical standpoint.”

Bauchner said he thinks health IT can help incorporate level A evidence into EHRs. The question, he said, when considering safety, quality and variation, is “how can we create a horizontal view of these issues so there can be progress in health outcomes? The key will be health IT.” 

Health IT + guidelines = value, he said. “EHRs must become smarter. We have to go beyond scouting and linking databases.” He said big data makes him nervous. “I’m not sure anyone knows where we’re going.” A focus on “little data” might be better than “extravagant themes of the future.” 

Making CDS work

America has a compelling issue to solve: medical errors. For every 1,000 patients coming in for outpatient care, 14 patients experience life-threatening or serious adverse drug events. For every 1,000 prescriptions written, 40 have medical errors and for every 1,000 women with a marginally abnormal mammogram, 360 will not receive appropriate follow-up care, said David W. Bates, MD, MSc, senior vice president for quality and safety at Brigham and Women’s Hospital in Boston.

To improve upon these error rates, clinical decision support (CDS) must fit into users’ workflows, he said. Physicians resist stopping, but providing them with an option has been shown to have a higher chance of success. 

It’s also important to monitor feedback and respond to that. “Knowledge-based systems have to be managed and maintained and a lot of systems don’t have a robust approach to do so,” Bates said. “You can produce big improvements at multiple stages if the technologies are in place.” 

CDS can deliver great value, he said. “Most EHR benefits come from decision support.” To date, most implementations are very limited. “We’re only scraping the surface of this whole area.” 

Worse than we thought

“Overall, the newest studies of patient safety should not be used to congratulate ourselves on how we’re doing but raise concerns that we haven’t made more improvements,” according to David C. Classen, MD, MS, CMIO of Pascal Metrics and assistant professor of the department of medicine at the University of Utah. Those reports estimate 200,000 to 400,000 patient deaths due to medical errors every year. 

“The best evidence we have is inpatient focused, particularly on medication safety. Beyond that, the evidence evaporates pretty quickly.” The field is a critical area for more research and development. 

An Office of the Inspector General report indicated that one-third of Medicare patients are suffering patient safety incidents as part of their hospitalizations. “Probably 180,000 deaths in Medicare patients alone every year are related to medication errors in the hospital. That’s double what the Institute of Medicine reported in 1999.” This is happening even in hospitals with very sophisticated health IT systems, he said. 

Studies show that patients who experience one complication have a 30 percent increased risk of experiencing another complication, Classen said. That more than doubles the risk of death, increases length of stay and increases the cost of hospitalization. “We’re also now finding out that it markedly increases risk of readmission­—by a factor of 3. That risk doesn’t stop at 30 days either—it lasts for one year.”  

Given all these disturbing figures, Classen pointed out that “the state of patient safety won’t improve until we improve our measurement.” 

About 10 years ago, he noted, the airline industry started to send data from airplanes back to an operation center every 30 seconds for evaluation, and notify the crew if need be. “We’re just now beginning to replicate that in healthcare.” 

Medicine a ‘sea of failure’

The aviation theme continued with Capt. Sullenberger who said his dramatic landing of his plane in the Hudson River in January 2009 was the result of “lifelong preparation.” 

“Bad outcomes are almost never the result of a single incident but are the end result of a causal chain of events.”

Prior to the Hudson River flight, Sullenberger was most proud of his contributions to changing cockpit culture, he said. There used to be a terrible accident rate and a lot of that was due to the arrogance of pilots who didn’t build teams. “They were solo acts and the accident rate reflected that.” 

After decades of technical improvements, “finally in the 1980s we began to attack the human component.” Sullenberger taught the first class that aimed to teach airline employees to be both better leaders and followers and flatten the hierarchy in aviation. “That’s critically important because we fly all the time with people we’ve never met before.” 

Detailed and carefully followed airplane chestlists and protocols help provide the consistency among strangers—with experience the detail that most often makes the difference in a crisis, both in a cockpit or hospital, he noted. 

“Throughout my career, I reminded myself to strive for excellence. Good enough isn’t. I never knew on which 208 seconds my entire career would be judged. I avoided complacency in spite of how commonplace air travel has been. That Hudson River flight was completely routine and unremarkable for the first 100 seconds. Then it became our ultimate challenge and we knew it as it was happening.”

After the miracle landing, he began to hear from colleagues and others from his past and realized that “my reputation had been built one interaction, one person, one day at a time. That’s true in each of our lives. In every encounter, there is the opportunity for good, ill or indifference. We have to choose which it’s going to be.” 

“Medicine has islands of excellence in a sea of failure,” Sullenberger said. Preventable deaths are seen as unintended consequences. There is more complexity in medicine than aviation but that doesn’t explain away all the negative outcomes, he said. Medication errors are really system errors. The 200,000 annual preventable deaths translate to three jetliners crashing every day. 

“I am an eternal optimist,” he said. “I believe you will eventually find a way to reduce the number of preventable deaths. The question is when. In 20 years after four million more preventable deaths? My vote is no.” 

Looking for More? Find in-depth coverage on HealthcareLeadershipForum.net and watch video interviews at HCLF.net/videos

 

Beth Walsh,

Editor

Editor Beth earned a bachelor’s degree in journalism and master’s in health communication. She has worked in hospital, academic and publishing settings over the past 20 years. Beth joined TriMed in 2005, as editor of CMIO and Clinical Innovation + Technology. When not covering all things related to health IT, she spends time with her husband and three children.

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