HM Leaders Call for Thoughtful, Budget-Minded Advancement of Patient-Safety Reforms


In a Venn diagram, patient handoffs would fall at the intersection of quality improvement (QI), patient safety, and technology.

Vineet Arora, MD, MPP, FACP, FHM, associate professor of medicine at the University of Chicago, wants hospitalists to understand that best practices in transitional care only work efficiently if they incorporate pieces from all three spheres. Hospitalists who focus too much on the outcome of an individual case might fail to utilize technology that could create a systemic protocol that would improve outcomes across multiple cases, she says. Similarly, hospitalists who leave notes in an electronic health record (EHR) can mistakenly believe that the next physician will interpret that information perfectly despite a lack of verbal and physical cues that guide verbal communication.

Dr. Arora

“People may fall into the fallacy that electronic health records actually equal good handoffs,” says Dr. Arora, a faculty member at HM12 last month in San Diego who led a breakout session that focused on the obstacles of handoffs. “The challenge is that handoffs actually are about a verbal exchange of informationa conversation and a dialogue, in conjunction with and supplemented with written communication. Technology certainly has the ability to revolutionize the way we review information and access information, but it will not change the way we speak about the information.”

The crossroads of patient safety, QI, and the use of technology from medical devices to iPhones was a major theme at SHM’s annual meeting, April 1-4 at the San Diego Convention Center. Hospitalist leaders agree that clinicians must focus on all three tenets to improve healthcare delivery, particularly in the face of generational healthcare reform. But they also acknowledge that finding a balance between best practices, budget and staffing constraints, and the rigors of daily practice is difficult.

Hospitalist Mark Lyons, MD, who works on residency programs and a patient-handoff initiative at Methodist Health System of Dallas, says that sessions on QI and patient safety provide new ideas from industry leaders who are in the trenches. To wit, he was impressed by the suggestions from Dr. Arora’s handoffs session as she described cases in which she was involved.

“They understand the limitations and the other things that go along with doing the actual act itself,” Dr. Lyons says. “They understand those things and take them into consideration. And you appreciate that.”

He and other hospitalists at HM12 agree that when leading practices are promoted at national forums, they take on the imprimatur of evidence-based procedures that physicians want to bring back to their respective HM groups. And QI suggestions promoted by physicians, not management, often tend to be more readily accepted.

“When you force change upon people, then it really leads to resistance,” Dr. Lyons says. “These are good opportunities to learn different strategies, to learn easier ways to present new ideas to people, to encourage them to do better, and to make it easier for them to do those things.”

Dave Garland, left, of Seattle-based Simulab Corp., demonstrates a portable ultrasound machine in the HM12 exhibit hall.

Dr. Arora

Anuj Dalal, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston, says technology can range from global EHRs across a multiple-institutional health system to microblogs to practice-centered wikis that promote communication between physicians. But integrating those technologies into care delivery that improves outcomes hinges not on technical hurdles, but on physicians accepting their validity and utility, he says. Once clinicians start digitally codifying the informal communication tools they currently use, patient-specific communication can improve.

And while Dr. Dalal, who co-led a session on the use of wikis as a communication-management strategy, adds that despite the little research linking those technological tacks to patient outcomes, he believes they are related.

“We’re using our devices, our iPads, our iPhones, our Android devices, to send information to other providers, but that information may not be transparent to other people,” says Dr. Dalal, who heads an SHM technology subcommittee. “But if you have it on a blog, a patient-specific Facebook, or a patient-specific Twitter, than everyone who subscribes to that will have access to the whole discussion.”

Dr. Dalal cautions that the details of legal compliance are important to ensure private patient information is safely transmitted. He anticipates vendors will market products that will balance the need for that privacy with a wider dissemination of information to ensure all involved physicians know what they need to know. One example: He expects the internal-messaging components of EHRs to improve in the next few years.

“It wouldn’t surprise me if these companies start realizing we need to support patient-specific communication in informal dialogues using microblogs and mobile devices,” he adds. “If they don’t do that, they’re probably going to miss the boat.”

The power of technology, large and small, must be balanced with what hospitalist pioneer Robert Wachter, MD, MHM, calls “foundational knowledge.” Dr. Wachter, who counts chair-elect of the American Board of Internal Medicine (ABIM) among his myriad titles, says that hospitalists can’t be slaves to technology. He relates it to a well-known adage in the aviation industry in which planes have become so advanced that some pilots would be incapable of flying them should the technology fail. In one quip, it is said that two people will soon populate cockpits: a pilot and a dog. The pilot’s job is to feed the dog, while the dog’s job is to bite the pilot’s hand if he tries to touch the controls.

Dr. Wachter

“As we move quickly, briskly, appropriately into this new world of computerization, if we aren’t constantly asking ourselves what have we lost in terms of our relationship with patients, we will really screw things up,” Dr. Wachter says. “This is not an argument to be Luddites, it’s not an argument to send back your meaningful use and get rid of the computers. We need them, but we have to be very thoughtful about how we maintain this balance.”

Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist and chief medical officer of the Centers for Medicare & Medicaid Services (CMS), says that to tie quality, safety, and technology together, government has to be willing to back therapies, then determine whether their efficacy deserves financial coverage.

One example Dr. Conway cites is the use of intravascular shunts. After backing their use initially for Medicare patients, it was determined that compared with medical management, the therapy had greater risks for death and stroke—and cost about 100 times more. Still, Dr. Conway says, determining how well the shunt works is exactly the process medicine should go through.

“When we have these new technologies that made a promise, we want to get them to market where they might help patients, but we also want to make sure evidence is developed to make sure they truly benefit patients,” he says, later adding, “I think this catalyst for health system transformation is important, and it’s teaching vision coupled with that execution.”

A well-planned blending of quality and technology can lead to improved patient safety, Dr. Arora says. But physicians and HM group leaders have to be proactive. Those with a clinical focus must seek out their IT counterparts and provide guidance on what information users need to access from electronic interfaces. Chief medical information officers and their staffs must seek feedback from providers before creating templates that don’t serve the clinical functions of end users.

Put simply: The fight to improve outcomes requires all parties to be properly armed. “You can choose a weapon,” she adds, “but you still have to choose it wisely and customize it to fit the needs of your organization.”

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