An editorial by cardiologist Sandeep Jauhar published in the New York Times in December presents a persuasive argument for balancing evidence-based care with human judgment so as to provide “personalized” care, not “homogenized” care. Eliminating variations in practice is an important goal but is an ongoing endeavor, given the ever-changing nature of the evidence.
In “Don’t Homogenize Health Care,” Dr. Jauhar asserts that presenting the evidence can’t be the be-all end-all for medical decisions. For example, for brand new treatment methods, there is no evidence yet. For others, the evidence is outdated. “What is in vogue today is often discarded tomorrow,” Jauhar says, noting that beta blockers for non-cardiac surgical patients were routinely recommended, but are now understood to increase the risk of stroke for some patients. And patient preference is also an important input to the decision-making process, and may countermand standard practice.
As American College of Cardiology President Patrick T. O’Gara noted in his defense of a reversal of a major recommendation for heart attack treatment: “Science is not static but rather constantly evolving.”
“Neither the old approach, in which seemingly every patient was treated differently, nor the new one, where we try to treat them all the same, has worked well. Medicine needs another way,” Jauhar writes. In 2015, healthcare could move in a number of directions to foster personalized patient care with better clinical outcomes—including genomic research.
Here at QPID Health we’ve committed to an evolving platform that can change as clinical knowledge broadens. We were pleased to hear such a compelling argument for our design principles from Dr. Jauhar.
Today we announced that Afik Gal has joined QPID Health as Vice President of Product Innovation. (Read the announcement here.)We are excited to have Afik join us because he has a unique background in innovative solutions for healthcare problems, and medical training and practice.
Afik’s joining the team is indicative of two core principles for QPID Health: our commitment to support the work that clinicians do, and our commitment to growing our clinical team. We have doctors, nurses and other allied health professionals on staff and as part of our ecosystem. They work across the QPID Health organization in account management, customer support, product planning, and content development. They add knowledge and sensibility to what we do.
Clinical knowledge is foundational for QPID. Clinicians love our solutions because they capture and anticipate the thinking processes of clinicians. For example, QPID applies clinical reasoning to surface a whole package of associated patient factors so a caregiver can understand the big picture of a disease or determine the best care pathway.
Clinical sensibility is another core principle. Our clinical colleagues know what it’s like to take care of patients and be responsible for decisions that have such a tremendous impact on the patient herself, her family, her co-workers and her community.
So here’s a big THANK YOU to my colleagues Nurse Pat, Nurse Connie, Nurse Judy, Nurse Diane, Nurse Karen, Doctor Sid, Doctor Mike, Doctor Afik, dieticians Alli and Janine, and dozens of others who are work daily with QPID to keep our clinical foundation strong and growing. Thank you as well to the 1000s of doctors, nurses, and other health professionals who provide direct and implicit feedback by using our products every day.
“Spurred on by renewed investment in digital health and government health reform, hundreds of startups are now working to address friction points and broken systems within health care.
But only a select number of those startups will find their niche and become vital parts of the system for the long haul. These startups will be the ones that have the best products and the clearest vision of where their part of the industry is headed. They’re the ones that empower patients, improve outcomes, manage costs, and reduce waste.
It’s these kinds of companies that we sought out for the Innovation Showcase at HealthBeat 2014.”
Mike Doyle, CEO of QPID Health, was asked to provide his comments to Alison Diana of InformationWeek Healthcare (Oct. 3) on the news from Texas that a patient later diagnosed with Ebola had been released to his home after his first hospital visit. Apparently a nurse had documented that the patient had been in Liberia, but this may not have been noticed or considered by the physician.
Mike helped shed further light on the problem:
I don’t think anyone would argue if that [Texas] physician had known that person was from West Africa he would not have discharged that patient. Unfortunately, in today’s healthcare world, data is very, very siloed. Inpatient systems don’t talk to outpatient systems. Eighty percent of data in electronic health systems is unstructured so it’s very hard to report. As a result, critical and acute information goes unnoticed — and this is a very prime example of that.
Although Texas Presbyterian Hospital first blamed the issue on the design of its EHR, they later retracted that. While the facts of this case remain unclear, the reality is that today’s EHRs bury essential information. As noted in the article:
Many hospitals complain about interoperability problems within their EHRs — between disparate workgroups, such as doctors and nurses, or different departments, including emergency rooms and cardiology — that lead to errors. The technology is new and many providers are in the early stages of adoption, seeking software and procedures that fine-tune capabilities and eliminate mistakes like this, experts said. Having evolved from billing, newer systems now focus more on clinician and patient needs, they said, and these later editions provide more of the capabilities, tools, and features medical users need.
The author notes that to address these issues “healthcare providers can purchase third-party products, such as QPID Health’s clinical intelligence software, that discerns patient information from EHRs and other sources, and then delivers it to clinical and administrative workflows.” QPID Health is adding specific Ebola-screening functions to our software, Mike also explained.
QPID Health is committed to making healthcare better, and to a world in which the IT systems we use enhance the ability of nurses, doctors and patients to communicate and take the best course of action.
Two recent studies with findings summarized in JAMA caught our eye because they provide interesting proof points on the value and need for “operationalizing” best practice guidelines as a hedge against habit and, sometimes, fear.
Both studies suggest that physicians may have a hard time being judges of the reasoning behind their own decision-making. And that old habits die hard!
Per lead author Dr. Michael Rothberg, “Some people might say it’s defensive, and other people might think it’s the standard of care. “There’s really more of a culture about how people treat a particular problem, and many may not recognize it as being defensive. […] Clear communication about evidence-based guidelines and tort reform that would protect clinicians when they follow those guidelines would help reduce providers’ fear and improve patient care.”
“Various efforts to reduce the perceived overuse of cardiac telemetry at Christiana Care Health System, a 1100-bed tertiary care system, were unsuccessful. In August 2012 we convened a team to increase the appropriate use of non-ICU cardiac telemetry through the integration of AHA guidelines into our electronic ordering system.”
Results were dramatic.
“After the changes, the researchers found the hospital group’s mean daily number of non-ICU patients monitored with telemetry fell by 70%, from 357.5 to 109.1, while the mean daily cost for delivering non-ICU telemetry also fell by 70%, from $18,971 to $5,772. The changes had no negative effect on patient care; mortality rates at the hospitals remained stable, as did the number of “code blue” emergency calls to resuscitate patients.” (“Hospitals Cut Costs by Getting Doctors to Stick to Guidelines,” Wall Street Journal, Sept. 22, 2014)
Our takeaway: Operationalizing best practice guidelines by incorporating those guidelines in software is a valuable tool for changing entrenched behavior.
P.S. QPID Health helps providers address utilization issues with our Q-Guide solution. Q-Guide counterbalances the adverse effect of accidental, “defensively-motivated” procedures and habits, which are brought to light in the JAMA studies.
QPID Health’s Mike Doyle has been invited to join the ChicagoConversations panel on Data Driven Decision Making in Healthcare. A Chicago Booth School of Business alumnus, Mike’s background in optimizing healthcare in the age of EHRs will enrich the conversation. You can learn more and register here for the event to be held at 6:30 pm in San Francisco.
The discussion will be focused on the challenges of achieving the promised benefits of digital health:
The implementation of electronic health records (EHR), advent of mobile health, and increasingly sophisticated data analytics are rapidly changing the health care industry, and the industry is poised to bring the advancements necessary to create a leaner, savvier, more efficient health care system. Benefits include: evidence-based, cost-effective treatments, remote monitoring and telemedicine, increased awareness of patient risks and preventative care implementation, and improved fraud and abuse detection.
Yet, before those benefits can be reaped there are a number of challenges to explore. How can data be structured consistently and converted into real-time analytics that are both accessible and secure? What are the barriers to interoperability and information exchange (required by the HITECH Act’s Meaningful Use Stage 2), and how can they be addressed? What measures can be taken to overcome the security and privacy risks posed by mobile devices and cloud services?
Chicago Booth invites you to San Francisco for a discussion with Chicago Booth alumni and industry leaders, who will share their expertise and perspective on the current conditions as well as their views on the future outlook for the health care industry.
Mike Zalis, QPID Health’s co-founder and chief medical officer, was asked to contribute a guest blog post on the broad theme of “Digital Health” in the EMR & EHR online forum. The forum covers issues related to EHR selection, implementation and Meaningful Use. According to Dr. Zalis:
To me, Digital Health means making every clinician the smartest in the room. It’s filtering the right information—organized fluidly according to the clinical concepts and complex guidelines that organize best practice—to empower clinicians to best serve our patients. Further, when Digital Health matures, the technology won’t make us think less—it allows us to think more, by thinking alongside us. For the foreseeable future, human experience, intuition and judgment will remain pillars of excellent clinical practice. Digital tools that permit us to exercise those uniquely human capabilities more effectively and efficiently are key to delivering a financially sustainable, high quality care at scale.
Mike’s sentiment that technology can provide welcome support for clinicians is echoed by David Ting of Mass General Hospital (MGH). In an interview published in HealthITAnalytics, Dr. Ting described the roll-out of QPID-powered predictive analytics and decision support at MGH:
Initially, the leadership was very excited about this, but we were a little nervous about how our surgeons would respond. Would they think that now a robot is telling them what is appropriate to do? As it turns out the surgeons love it….
Surgeons, even the world-renowned surgeons, do not want to operate on a patient who’s going to die on the table. The last thing they want is to do harm to a patient or do something inappropriately….
It turns out that our surgeons are relieved that they have that kind of backup at their side, so rather than feeling insulted that the computer is kind of guiding their decisions, if anything, this is kind of the decision support that the surgeons are very, very interested in.
Alan Ezekowitz, MBChB, D.Phil., FAAP is Co-Founder, President and CEO of Abide Therapeutics. We welcome Alan as the newest member of the QPID Health Advisory Board, announced in April. He is a pioneer in the field of innate immunity and previously served as senior vice president and franchise head of endocrine, bone, respiratory, and immunology at Merck Research Laboratories. He also served on the staff of Children’s Hospital of Boston, and later was chief of Pediatric Services and chaired the Executive Committee on Research at Massachusetts General Hospital.
Our Advisory Board is a group of nationally recognized experts in medicine, policy and healthcare IT who provide strategic guidance to our company. Over the past year, QPID Health has grown tremendously—rolling out new products and expanding both our customer and employee bases. Our Advisory Board members speak to the concerns of healthcare providers and guide us on corporate and product strategy as we continue to grow as a company.
Mike Doyle, our CEO, says of the Advisory Board, “We are honored to have attracted this group of esteemed healthcare scholars and leaders who share our passion for helping clinicians deliver the best possible care to patients while addressing issues of cost and efficiency.”
The members of the QPID Health Advisory Board are:
David W. Bates, MD, MSc, Chief of the Division of General Internal Medicine and Primary Care at Brigham and Women’s Hospital, Professor of Medicine at Harvard Medical School, and Professor of Health Policy and Management at the Harvard School of Public Health.
Alan Ezekowitz, MBChB, D.Phil., FAAP, Co-Founder, President and CEO of Abide Therapeutics
John D. Halamka, MD, MS, a Professor of Medicine at Harvard Medical School and Chief Information Officer of Beth Israel Deaconess Medical Center.
Julia Adler-Milstein, PhD, an Assistant Professor at University of Michigan whose research focuses on policy and management issues related to the use of IT in healthcare delivery.
John E. Osborn, JD, MIPP, a senior advisor with the international law firm Hogan Lovells, executive in residence with the healthcare group of Warburg Pincus, a regular contributor to Forbes.com and a faculty member at the University of Washington, Seattle.
Robert M. Wachter, MD, a Professor of Medicine at the University of California, San Francisco (UCSF), Associate Chairman of UCSF’s Department of Medicine, and Chief of UCSF’s 60-faculty Division of Hospital Medicine.
We read a thoughtful piece by Lindsay Dunn in Becker’s Hospital Review blog (Disruption Overkill) questioning the necessity for “Disruptive Innovation” to make the changes we need in healthcare.
The much-ballyhooed buzzword — and debunking of the academic theory behind it — is the subject of a recent New Yorker article. (It’s great fun to read!) According to the author, historian Jill Lepore, hospitals are not purely profit driven, so business theories need not apply. While attacking her Harvard colleague Clay Christensen she notes:
Innovation and disruption are ideas that originated in the arena of business but which have since been applied to arenas whose values and goals are remote from the values and goals of business. People aren’t disk drives. Public schools, colleges and universities, churches, museums, and many hospitals, all of which have been subjected to disruptive innovation, have revenues and expenses and infrastructures, but they aren’t industries in the same way that manufacturers of hard-disk drives or truck engines or drygoods are industries.
Dunn seems inspired by Lepore when she describes the need for change and innovation without using the “D-word.”
Hospitals are in the midst of an era of significant — and perhaps unprecedented — change. We’ll have to innovate, and we’ll have to change our business models to better meet the demands of our payers and patients for higher-value, more transparent care.
How about #Constructive_Innovation for healthcare?
Most of the news we’ve seen on the topic of costs associated with EHRs relates to financial losses for hospitals, not cost savings. So a study published in the American Journal of Managed Care showing per patient savings of nearly 10% caught our eye.
The study (Association of Electronic Health Records With Cost Savings in a National Sample) looked at 5 million inpatient records at 550 acute care hospitals. The authors found savings per adult patient admission of $731, or 9.6%, in the 19% of hospitals using “advanced EHRs” (“consistent with the first requirements of Meaningful Use”). The study, conducted in 2009, concluded that patients, third party payers and hospitals could benefit from these lower costs.
In an interview in HealthLeaders, co-author Abby Kazley provided additional insight, including that similar studies on pediatric populations failed to show improvements. Work remains to truly assess the impact of EHRs and make the right adjustments to leverage the investment made. When asked “what’s next” she said:
We need to continue to look at the cost and the quality of the care associated with EHRs and we need to look at individual organizations and do system evaluations to see how well the EHRs themselves are working.
We applaud the use of EHRs and are happy to see these cost savings documented. Our mission at QPID Health is to see that hospitals achieve further cost savings while providing the best care possible – by activating the clinical intelligence that EHRs contain.
With the US continuing to outspend other industrialized nations by a long shot (17.6% of GDP versus 9.2%, or $8,745 versus $3,355 per the Commonwealth Fund) but failing to achieve better outcomes, we are headed in the right direction but have a long way to go.