Shocking Finding: E-Prescribing Reduces Error Rate at Brigham and Women's Hospital!

OK, this is certainly not a surprising finding. What I don't understand is why aren't more hospitals using this technology in prescribing drugs for their patients? It is a no-brainer. From HealthLeaders:

Using bar-code technology can substantially reduce transcription and medication errors, and prevent potential adverse events, according to a new study funded by the Agency for Healthcare Research and Quality.

Researchers at Brigham and Women's Hospital in Boston compared error rates in order transcription and medication administration at an academic medical center before and after it implemented a bar-code electronic medication-administration system (eMAR). The eMar system sends electronic alerts when a patient's medication is overdue or if there is a mismatch between the bar codes on a patient's wristband and the medication.

Of the 14,041 medication administrations and 3082 order transcriptions researchers reviewed, they noted 776 errors unrelated to timing on intensive care units that did not use the bar-code eMAR, compared to just 495 on units that had implemented the system--a 41.4% relative reduction in errors.

The rate of potential adverse drug events also fell just over 50%, and the rate of timing errors in medication administration dropped by 27.3%. The authors extrapolated those results to estimate the potential impact on the hospital over the course of a year.

"Because the study hospital administers approximately 5.9 million doses of medications per year, use of the [bar code system] is expected to prevent approximately 95,000 potential adverse drug events at the point of medication administration every year in this hospital," researchers wrote in their report, which was published in the May 6 issue of the New England Journal of Medicine.

In addition, they expect the technology to reduce the number of early or late medication administrations by 270,000 per year and to prevent approximately 50,000 potential adverse drug events related to transcription errors.

EMR Benefit: Disease Mapping Across Communities

Electronic medical records have been hailed for their potential to make care more cost efficient those some in the provider community have their doubts. In Durham, NC another benefit of EMRs has been realized (from HealthLeaders):

When Durham-based Duke University and the Durham, NC, community launched Durham Health Innovations (DHI) in April 2009, they knew they were embarking on a groundbreaking project that would use medical informatics to identify chronic disease interventions and improve the health of patients. But at some point during the recently completed planning stages of the project, team members realized that they had stopped talking about patients—and started talking about communities.

"We realized that we were doing a whole lot of work on individuals," says Lloyd Michener, MD, chair of the Department of Community and Family Medicine at Duke. "Until this project, we hadn't clearly seen how individuals were part of the same networks, the same communities, and the same neighborhoods. In many cases, it makes sense to do things at the community and neighborhood level rather than one at a time at an expensive doctor's office."

The project uses data from Duke's electronic medical records (EMR) system. The university runs customized software that assigns geographic locations to the data, also known as geocoding. This HIPAA-compliant process lets team members look at areas of disease clustering.

The technology allows DHI to track progress and create interventions to prevent health problems from worsening in real time, says Gayle Harris, public health director in Durham County and member of the DHI oversight committee. The disease clustering maps are "amazing," says Harris, adding that they helped DHI identify disease hot spots at the neighborhood level.

"We shared the data with community members so they could see the patterns of illnesses that were affecting the community and the burden that imposed and talk about the interventions they would like to implement," says Michener. "It helped the communities galvanize and come together to find solutions."

Ten disease-based project teams, composed of diverse members from the Duke health system and the Durham community, used the data to develop plans to reduce death or disability from specific diseases and improve overall health outcomes.

"This is actually fairly exciting," says Michener. "With all the talk about unhappy doctors and patients and healthcare not working, this feels like people starting to take control of their own destiny and saying we can do better."

DHI project teams are now in the process of implementing their plans to evoke long-term change in the community. This month, Medicine on the 'Net® took the opportunity to follow up with them on the progress that they've made this past year.

It takes a village to improve health outcomes Michener was impressed by the deep level of interest that the project created in the tight-knit Durham community.

The project involved nearly 1,000 participants from Duke, the community, and 90 agencies who volunteered to work together to develop a better way of providing healthcare.

"This really brought the community together," Michener says. Team members involved in the project discovered that there were groups in the community that were working on similar issues, but that they weren't aware of one another's existence. "I couldn't count how many groups were working on obesity in the Durham community," he says. "The project let people connect and coalesce."

One of the teams has started working with a free clinic in the community to provide mammograms and cancer screenings using grant funding, says Harris. This opportunity came about because the project united people who wouldn't normally work with one another, she says. It helped them tap into current resources to put something in place that had been missing.

Project team members have garnered a new understanding of their community and have come away from the project feeling energized and ready to set their changes in motion.

"We've made a point of saying that health is everyone's business and it's going to take all of us," says Harris. "With that ongoing message, people will see that they have a part to play."

Targeting obesity—one child at a time
The obesity committee decided to tackle obesity in the Durham school system. The team believes that this will also allow them to affect change in parents, teachers, and other members of the community. They selected a target school as part of their first-year effort, and it has been cooperating with their efforts.

"The school system was the lowest-hanging fruit in terms of the obesity project," says David Reese, MBA, chief operating officer of the Inter-Faith Food Shuttle and vice chair of the Partnership for a Healthy Durham, where he co-chairs its obesity and chronic illness committee.

"It was a demographic in which we had the ability to affect the greatest change." Duke's EMR system did not store data on weight checks, and some of the children were not in the Duke system. As a result, the team needed to visit the school to gather the vital data that were missing. They collected the heights and weights of all the students at the target school to identify overweight children.

They are currently in the process of implementing a nutrition-based cooking class called Operation Frontline. The school is also applying for a USDA grant that could provide healthy fruit and vegetables to the school.

Reese says the team will move cautiously and at a sustainable pace during the first year. He is optimistic about the project and believes it will yield "tremendous results." Without the project, he says efforts to tackle this obesity in the community would continue to be fragmented.

Creating a community health system
One unexpected outcome from the project was the community's support of having their healthcare data shared across providers. "They were actually comfortable with data being shared and aggregated so we could look at how problems affected their neighborhoods," says Michener.

In one example of data sharing, project team members discussed the benefits of creating a common, patient-centered medication list so they didn't have to reiterate their list of medications to every healthcare worker they saw.

Although members of the community support data sharing, they don't want a specific EMR to tie them down, especially one owned by Duke. Likewise, Duke doesn't want the responsibility that comes with owning large amounts of patient data.

Duke has already determined that it currently stores too much information and is trying to limit it to 20 to 50 data points. As a result of project team discussions, DHI team members no longer believe they need a single electronic medical record system for Durham county. Instead, they are now discussing how to create a common health record that allows them to share and aggregate data in their community.

"That's a major conceptual shifting," says Michener. If DHI can develop a common health record, he says annoyances such as medication lists will become a thing of the past. Such a health record could update and share medication lists across multiple providers.

"We're actually looking at a wireless community in which health related data is shared—with permission—freely across the health system," says Michener. "It's a rethinking of healthcare. Chronic disease is a major problem in healthcare. You can't just deal with this in the hospital and medical setting. You have to include the churches, schools, the health department, and the workplaces in the environment."

In addition to the Duke data, the project teams determined that they want to collect information from non– health system sites such as workplaces and schools (with permission) and upload the data to a single database.

"There's still a lot of work to be done, but the whole notion of having a plan that the community embraces is just such a good thing," Harris says.

GAO to CMS: Monitor Bundled Payments to ESRD Patients

As I have mentioned in previous posts, I think that bundled payments are one of the critical ways to control the cost of health care in this country. Obviously given its dominant funding position, the Medicare program's experience in bundling payments will be important to watch. The Government Accountability Office recently released a report on Medicare's pilot program to bundle payments for Medicare recipients with ESRD scheduled to begin 01/01/11. Highlights follow:

Under the current fee-for-service system of payment, certain demographic groups showed above average Medicare expenses for injectable ESRD drugs. For example, Medicare spent $782 per month in 2007 on injectable ESRD drugs for each African American beneficiary. This was nearly 13% higher than the average for all beneficiaries on dialysis and also was higher than for other racial groups.

In addition, monthly Medicare spending for beneficiaries with additional coverage through Medicaid was about 6% higher than the average across all beneficiaries on dialysis.

Although GAO did not identify those factors that created these differences, staff did obtain information from 73 nephrology clinicians and researchers on the factors that they thought would result in above average doses of injectable ESRD drugs. This included more than a dozen factors—such as chronic blood loss and low iron stores—as likely to result in above average doses of injectable ESRD drugs.

As required by law, CMS's proposed design for the new payment system for dialysis care includes two payment mechanisms to address differences among beneficiaries in their costs of dialysis care.

With the first payment mechanism—a case mix adjustment—CMS proposes to adjust payments based on characteristics such as age, sex, and certain clinical conditions, which are associated with beneficiaries' costs of dialysis care. The second proposed payment mechanism—an outlier policy—calls for making additional payments to providers when they treat patients whose costs of care are substantially higher than would be expected.

Missing from these preliminary plans, though, is to what extent CMS will monitor the effects on the quality of and access to dialysis care for different groups of beneficiaries. In particular, these areas should focus on above average costs of dialysis care under the new bundled payment system, GAO said.

This monitoring should begin as soon as possible once the new bundled payment system is implemented and should be used to create potential refinements to the payment system, GAO added.

Medical Homes Save Money!

Yesterday I talked about a study that revealed how little medical students learn about the costs of health care. Bundled payments, I said, is one way to provide the incentive for docs to pay attention to the cost of care. Medical homes are another way to get primary care docs involved in providing more effective care. So do patients in medical homes use fewer resources? A story from Kaiser Health News revealed the following:

Some health policy experts and clinicians have long maintained that, in the effort to reduce health care costs and improve patient outcomes, there's no place like (a medical) home.

A new study in the May issue of the journal Health Affairs seems to validate that notion.

Medical homes — where primary care doctors are held responsible for coordinating care for individual patients – are seen as a model for lowering costs without sacrificing quality. (Related story: Living In A Medical 'Home’).

Dr. Rob Reid and colleagues from the Group Health Research Institute examined the costs and patient outcomes from a team of medical professionals providing care for 10,000 patients at a Seattle-area Group Health "medical home." The conclusion? The medical home produced significant cost savings.

For example, during the two years studied, the team's patients had 29 percent fewer ER visits and 6 percent fewer hospitalizations compared with other Group Health clinic patients. There were start-up costs — $16 per patient per year — and results took a couple years to provide the bulk of the savings. But, ultimately, Reid said that for every $1 it invested in the system, Group Health saved $1.50 by keeping patients out of the ER and the hospital. And the medical home patients "reported better care experiences" as well.

The strategy is now being expanded to all 26 of Group Health's Washington state medical centers — covering more than 400,000 patients. Reid, in an interview, called primary care "a real team sport where the primary care clinician is the quarterback."

If such plans sound like managed care organizations such as Kaiser Permanente, that's because they have a lot in common, including the primary care doctor at the center. But patients at Group Health can self-refer to certain specialists and the approach rewards doctors, not simply the organization, to improve health outcomes.

There's evidence that the medical home, "works and works very well," said HHS Secretary Kathleen Sebelius, at a Tuesday Health Affairs briefing. She also noted that primary care will be important to transitioning to a lower-cost health care system in America. But historically, it's been difficult to attract the necessary workforce needed to provide that type of care. "The reimbursement system clearly has penalized primary care providers over the last several decades," she said.

For instance, a second Health Affairs study says doctors could leave as much as $3 million on the table over the course of their careers by choosing primary care as their focus instead of certain specialties.

So it's no wonder that in order for the medical home model to be successful, a few things must be changed, according to Group Health's Reid: The payment system has to be changed to reward better outcomes and boost primary care, electronic medical records and e-health should become a focus and medical teams need to replace lone doctors as the primary providers of care.

As it stands, most doctors in America are paid per patient visit. Doctors at Group Health are on salary, but their salaries also have financial incentives built in — like increased payments if their patients are more satisfied or if they receive better quality scores for their care — something others say could pose significant cost savings if implemented elsewhere. With such changes, the reasoning goes, doctors get to spend more time with each patient because they're not focused on non-medical tasks. Getting doctors to buy in, however, is a significant task.

Speaking of Payment Provider Bundling

As a follow-up to my earlier post this morning, here is an excerpt on provider bundling from Modern Healthcare:

"Bundling payments to hospitals and doctors for episodes of care is gaining momentum in the federal government and in the private sector as a way to increase provider accountability and improve care -- but lingering challenges may deter its application on a broader scale." Demonstration programs that use bundling -- paying doctors and hospitals a fixed amount for a package of services or time period per patient -- have helped hospitals, patients and doctors, save money. The Obama administration also hopes it can help save Medicare $17 billion over a decade.

But, "'The private sector is right not to wait around' for the federal government to take the lead on bundling, says Deirdre Baggot, administrator for cardiac and vascular services at 361-bed Exempla St. Joseph Hospital in Denver. 'They want to explore this as a viable payment strategy.' ... Bundling has progressed more slowly at the federal level because of a series of snags, even though the concept has been on HHS' agenda for decades. Medicare in the 1990s conducted a successful demonstration on payment bundling for heart bypass procedures, but various explanations have been given for why the project hasn't become an actual payment model. What we were told by the CMS is the project was very successful, but that they lost focus trying to get ready for any Y2K problems, Baggot says"

OK Y2K was now over 10 yrs ago. I think CMS can move onto bundling. Obviously bundling was not a priority item for the Bush administration. It was too busy fighting unnecessary wars, cutting taxes for the wealthy and trying to privatize Social Security.

Future Doctors Need Better Training on Medical Costs

Good article (http://www.nytimes.com/2010/05/04/health/04cost.html?ref=science) in the NY Times today on the efforts of medical schools to teach their students about the cost of care. While efforts to do such training have improved there is still major room for improvement:

Nonetheless, the effort has not been universal. According to a recent A.A.M.C. survey, about 60 percent of 102 American and Canadian medical schools include some material on health care costs, although the time they devote to it varies widely.

Dr. Prescott said a separate survey of 155 large teaching hospitals that together sponsor more than two-thirds of accredited residency programs in the United States found that only 41 percent had made sure that all their residencies included material on health care costs.

The article goes onto describe how volunteering at health clinics is another way medical students and residents are exposed to cost issues.

So it is certainly not a surprise then that medical costs have been so hard to contain when both the people who prescribe them and the the people who receive them know show little about the cost of the care.

This is why I believe the movement towards bundled provider payments have such promise. It will force medical providers to really look at the cost and necessity of the care they prescribe. Consumers also have a role to play in the cost equation but I really believe medical professionals are in a much better position than the average consumer to make the correct call on the necessity of a particular procedure/test.

Study: EMR Saves Lives

In a previous post I noted that a study of the electronic medical record system employed by the VA has saved the American taxpayer money. Well today I would like to cite the first study that has showed that EMRs also save lives (from the Washington Post):

Doctors at a California children's hospital have found the first evidence that using an electronic system to communicate their orders may save lives.

After the system was introduced in 2007, the hospital witnessed a 20-percent drop in mortality rate, the equivalent of 36 fewer deaths over a year and a half.

"It's the lowest rate ever observed in a children's hospital," said Dr. Chris Longhurst, of Stanford University and Lucile Packard Children's Hospital in Palo Alto, California, whose findings are published in the journal Pediatrics. "It begs the question how many lives could be rescued on a national level."

In 1999, a report from the Institute of Medicine blamed medical errors for between 44,000 and 98,000 deaths per year in the United States. Many hospitals have since introduced so-called computerized physician order entry, or CPOE, in an effort to lower that number.

Such systems allow doctors to relay prescriptions to pharmacists without delay, and without the need for the pharmacist to decipher doctors' scrawl.

"What used to take 40 minutes or so now takes 20," Longhurst told Reuters Health.

Although close to three in ten U.S. hospitals use CPOE, no one had been able to show a decrease in mortality until now. In 2005, a Pittsburgh hospital even reported an increase in the number of child deaths after it implemented the system.

"There have been a couple of studies previously that have taken a similar approach and have found the opposite result" of the current study, said Nir Menachemi, an expert in health information technology and policy at the University of Alabama at Birmingham. "I was more surprised by those studies."

The debate over whether CPOE is working as intended is hardly over, said Menachemi: "I think it would be foolish to believe that any one study can end the discussion."

According to Longhurst, what set Packard Children's Hospital apart was its careful and well-planned implementation of CPOE.

He said the hospital, which has a total budget of between $600 and $700 million, had spent about $50 million on the project.

"We have realized some cost savings, but I could not tell you that we've saved money," he said.

However, the hospital has saved lives, it appears. When analyzing about eight years' worth of data, the researchers found that average mortality dropped from slightly more than one death per 100 hospital discharges to around 0.7 with the introduction of CPOE.

The system has also helped doctors limit some unnecessary procedures such as blood transfusions, which Packard Children's Hospital had overused, according to Longhurst.

While it's hard to prove that CPOE is directly responsible for the decrease in mortality -- which could have been brought about by other improvements during the same period -- the researchers did the best they could to account for those factors.

"The cards were almost stacked against finding positive results," said Menachemi, noting that the hospital had admitted more severely ill children after the new system was taken into use.

Despite the encouraging findings, Longhurst said he was concerned about President Obama's call for rapid implementation of the electronic system.

"It should be rolled out by experienced experts," he said. "And there are only so many experts in this country."