The Adoption/Certification Workgroup of the federal Health IT Policy Committee met March 12, 2010. The Patient Safety Working document and analysis are below. Here is the audio of the meeting:
Download
The workgroup proposed to create a new national database and reporting system to track health information technology-related hazards that could affect patient safety. In a draft paper discussed at their meeting they considered a national health IT reporting system where providers could report data on all incidents and potential hazards to a patient safety organization.
“Overall, patient safety is better in health care organizations with IT than in health care organizations without IT, provided that the IT systems have been implemented correctly, and provided that an appropriate improvement culture exists,” the paper states.
The paper also addresses four key areas where potential safety hazards exist. They include technology issues such as hardware failures and software bugs; complex interactions of professionals, workflows, and user interfaces; interoperability problems between applications (such as lab results never making it into the EHR) and implementation and training deficiencies.
“The complexity of the health care activity coupled with the number of individuals involved with an activity influences the probability of an incident,” according to the paper.
In the previous February 25, 2010 Adoption/Certification Workgroup meeting, Jeffrey Shuren, director of the FDA’s Center for Devices and Radiological Health, outlined some of the health and safety risks associated with health IT. Over the last two years, the FDA has received 260 reports of health IT-related malfunctions that could have potentially caused bodily harm, and did actually injure 44 people and kill another six, Shuren said.
These figures were supplied to the FDA voluntarily by patients, clinicians, and user facilities, so they may “represent only the tip of the iceberg in terms of the health IT-related problems that exist,” he said.
Shuren had said these adverse events fall into four categories: errors of commission, such as accessing the wrong patient’s record or overwriting one patient’s information with another’s; errors of omission or transmission, such as the loss or corruption of vital patient data; errors in data analysis, including medication dosing errors of several orders of magnitude; and incompatibility between multi-vendor software applications and systems, which can lead to any of the above. It seems the committee is responding to many of the FDA's concerns in this paper.
Under the draft plan, the national health IT reporting system ideally would be patient-centered and consistent with the vision of a learning health care system. “A ‘patient-centered’ approach focuses more on the patient and less on accountability for an error,” the draft proposal states. “We also want to focus attention on hazards and "near-misses". We want to prevent unsafe conditions that might lead to serious injuries or deaths.”
Showing posts with label patient-centered care. Show all posts
Showing posts with label patient-centered care. Show all posts
Friday, March 12, 2010
Friday, October 9, 2009
Patient Centered Medical Home
The fundamental challenge for health reform is to expand access, while changing the delivery system to provide higher quality care at a lower cost. Current reform success will require a shift in emphasis from fragmentation to coordination and from highly specialized care to primary care and prevention. The Patient Centered Medical Home (PCMH) model is one method to move us in this direction. The PCMH model is founded on 4 cornerstones: primary care, patient centered care, new model practice, and payment reform. Patient centered care is designed to meet the needs and preferences of patients.
The term "medical home" was first used in a book published by the American Academy of Pediatrics (AAP) in 1967 Pediatric Records and a "Medical Home" In: Standards of Child Care. The initial premise was that children with special needs (defined as children with severe chronic illness, developmental disabilities and birth defects or others with high care needs) should have care coordinated by a practice that provided "accessible, coordinated, family centered, culturally effective care by a pediatrician who in addition provides primary care and manages and/or facilitates all aspects of the care for these children."
While the PCMH would encourage patients to identify a medical home, the physician practice would function to inform, coordinate and facilitate specialty care where that care is likely to be of benefit to the patient. The proposed hybrid model of reimbursement includes a per patient per month or year payment, and that payment would be based on the degree to which the practice was using the technology, systems and care coordination specified in the PMCH. While the pay for performance component of the reimbursement might in part be based on resource use/cost, it would not necessarily differ in degree or focus from the same elements applied to sub-specialty practice.
A PCMH demonstration was undertaken Group Health, with the goals of improving patient experience, lessening staff burnout, improving quality, and reducing downstream costs. Five design principles guided development of the PCMH changes to staffing, scheduling, point-of-care, outreach, and management. Group Health provides healthcare insurance and comprehensive care to approximately half a million residents in the northwestern United States. Twenty primary care clinics are located in western Washington State, where patients choose a primary care physician to guide and coordinate their care. These physicians (81.6% family physicians, 3.5% general internists, and 14.9% pediatricians) care for an average of 2300 patients and work in multidisciplinary teams
The PCMH model outlines a payment structure that combines fee-for-service, pay-for-performance, and a separate payment for care coordination and integration. The payment structure is explicitly intended to provide compensation for care coordination, care management, and medical consultation outside the traditional face-to-face visit. The model also calls for financial recognition of case-mix differences, the adoption and use of clinical information technology for quality improvement, savings from reduced hospitalizations, and the achievement of quality targets.
Each of the 4 cornerstones of the PCMH model has its unique strengths and vulnerabilities. Another challenge to the success of the PCMH model is public perception. For some, "medical home" sounds a lot like a nursing home and initial resistance could be difficult to overcome. Also the expectation of short-term cost savings may be unrealistic in many areas. Implementation of the PCMH model will require infrastructure investment and retooling in the primary care practice.
Built on the four cornerstones of primary care, patient centered care, new model practice, and payment reform, the widely endorsed PCMH model has the potential to increase access and quality and to decrease the rate of growth in costs over time. As health reform gains momentum, the PCMH model will become increasingly important.
The term "medical home" was first used in a book published by the American Academy of Pediatrics (AAP) in 1967 Pediatric Records and a "Medical Home" In: Standards of Child Care. The initial premise was that children with special needs (defined as children with severe chronic illness, developmental disabilities and birth defects or others with high care needs) should have care coordinated by a practice that provided "accessible, coordinated, family centered, culturally effective care by a pediatrician who in addition provides primary care and manages and/or facilitates all aspects of the care for these children."
While the PCMH would encourage patients to identify a medical home, the physician practice would function to inform, coordinate and facilitate specialty care where that care is likely to be of benefit to the patient. The proposed hybrid model of reimbursement includes a per patient per month or year payment, and that payment would be based on the degree to which the practice was using the technology, systems and care coordination specified in the PMCH. While the pay for performance component of the reimbursement might in part be based on resource use/cost, it would not necessarily differ in degree or focus from the same elements applied to sub-specialty practice.
A PCMH demonstration was undertaken Group Health, with the goals of improving patient experience, lessening staff burnout, improving quality, and reducing downstream costs. Five design principles guided development of the PCMH changes to staffing, scheduling, point-of-care, outreach, and management. Group Health provides healthcare insurance and comprehensive care to approximately half a million residents in the northwestern United States. Twenty primary care clinics are located in western Washington State, where patients choose a primary care physician to guide and coordinate their care. These physicians (81.6% family physicians, 3.5% general internists, and 14.9% pediatricians) care for an average of 2300 patients and work in multidisciplinary teams
The PCMH model outlines a payment structure that combines fee-for-service, pay-for-performance, and a separate payment for care coordination and integration. The payment structure is explicitly intended to provide compensation for care coordination, care management, and medical consultation outside the traditional face-to-face visit. The model also calls for financial recognition of case-mix differences, the adoption and use of clinical information technology for quality improvement, savings from reduced hospitalizations, and the achievement of quality targets.
Each of the 4 cornerstones of the PCMH model has its unique strengths and vulnerabilities. Another challenge to the success of the PCMH model is public perception. For some, "medical home" sounds a lot like a nursing home and initial resistance could be difficult to overcome. Also the expectation of short-term cost savings may be unrealistic in many areas. Implementation of the PCMH model will require infrastructure investment and retooling in the primary care practice.
Built on the four cornerstones of primary care, patient centered care, new model practice, and payment reform, the widely endorsed PCMH model has the potential to increase access and quality and to decrease the rate of growth in costs over time. As health reform gains momentum, the PCMH model will become increasingly important.
Thursday, October 1, 2009
The Patient at the Center
The Planetree of Hippocrates in Kos, Greece
October is Patient Centered Awareness Month. The Tree of Hippocrates has become a symbol of patient centered care. This is the planetree under which, according to the legend, Hippocrates of Kos (considered the father of medicine) taught his pupils the art of medicine. The tree's association with Hippocrates is the source of the name of the Planetree, an organization of hospitals dedicated to personalizing, humanizing, and demystifying the healthcare experience. The Planetree philosophy is patient centered committed to improving medical care from the patient's perspective. Patients are encouraged to read their own medical records. Their pets are allowed to visit. Families are encouraged to participate in the patient's care, and can even prepare the patient's favorite dishes in special kitchens on each floor. In addition to the most modern and technologically advanced Western medical treatments, alternative options such as acupuncture and massage are offered.
At Planetree We Believe...
- That we are human beings, caring for other human beings.
- We are all caregivers.
- Care giving is best achieved through kindness and compassion.
- Safe, accessible, high quality care is fundamental to patient-centered care.
- In a holistic approach to meeting people's needs of body, mind and spirit.
- Families, friends and loved ones are vital to the healing process.
- Access to understandable health information can empower individuals to participate in their health care.
- The opportunity for individuals to make personal choices related to their care is essential.
- Physical environments can enhance healing, health and wellbeing.
- Illness can be a transformational experience for patients, families and caregivers.
"Your patient has no more right to all the truth you know than he has to all the medicine in your saddlebags.... He should get only just so much as is good for him.... It is a terrible thing to take away hope, every earthly hope, from a fellow creature... Some shrewd old physicians have a few phrases always on hand for patients who insist on knowing the pathology of their complaints without the slightest capacity of under standing the scientific explanation. I have known the term 'spinal irritation' to serve well on such occasions."The attitude of Holmes is obviously unacceptable today. Patients increasingly expect to know not only their diagnoses, but also details of pathophysiology, treatment options, and prognosis. These days patients often even challenge their physicians' diagnoses. Patients expect and often demand information that used to be only within the physicians' reach, and physicians increasingly expect that they will share information with patients.
The change in attitude surrounding disclosure of diagnoses stands out when discussing cancer. Not surprisingly, Holmes advocated that physicians avoid the term "carcinoma" when speaking with patients. He would be very uncomfortable at the Celilo Cancer Center where the Planetree philosophy of patient centered care is practiced. Of course there is a delicate balance of keeping hope alive and brutal honesty.
Beyond simply being honest, one argument for informing patients is that information enables patients to participate in medical decisions. In less patient centered days, physicians decided what was best for their patients, and patient participation was limited to compliance with physicians' orders. As the art of medicine becomes more patient centered, participation begins with the patient helping to make medical decisions, and the emphasis will shift from compliance to participation. Including the patient and the entire family in the decision making and care of the patient is important.
Of course, individual patients are different with respect to the amount of detail they want, and the degree to which they wish to participate in decision making. Therefore, the art of patient centered care involves determining the appropriate amount of information and participation from the individual patient's perspective. For some patients, the "right not to know" is a crucial element of patient centered care. For some patients it is not necessarily information that dtermines for them whether they are at the center of their care. The provider must not assume that certain types of patients, based on age, history, or other factors, will favor or disfavor information. This is a part of patient centered care that is very intuitive for the provider.
There is a great deal of interest now in the Patient Centered Medical Home (PCMH). This is a new approach to providing comprehensive primary care. The AAP, AAFP, ACP, and AOA, representing approximately 333,000 physicians, have developed the following joint principles to describe the characteristics of the PCMH:
Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.
Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
Quality and safety are hallmarks of the medical home:
- Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.
- Evidence-based medicine and clinical decision-support tools guide decision making
Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement. - Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
- Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication
- Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
- Patients and families participate in quality improvement activities at the practice level.
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:
- It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.
- It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
- It should support adoption and use of health information technology for quality improvement;
- It should support provision of enhanced communication access such as secure e-mail and telephone consultation;
- It should recognize the value of physician work associated with remote monitoring of clinical data using technology.
- It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
- It should recognize case mix differences in the patient population being treated within the practice.
- It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
- It should allow for additional payments for achieving measurable and continuous quality improvements.
"The Patient-Centered Medical Home model - described more fully in materials from the Patient-Centered Primary Care Collaborative, and TransforMED, an affiliate of the American Academy of Family Physicians - relies on a shift in physician compensation from a fee-for-service focus to a patient management focus; from an episodic focus to comprehensive, relationship-based care. It’s been implemented in over 100 pilots around the country. Denmark learned about the model here in the U.S. decades ago and have implemented it fully across the country’s health care system, shuttering most of the acute care hospitals in the country in the process. Pilots in the U.S. include Geisinger’s, which Grundy says has been remarkably successful, yielding an ROI of over 250%, including a 12% reduction in ER utilization, a 20% reduction in hospitalization, ans a 48% reduction in rehospitalization.I agree completely and recommend that you check out the entire interview. We are moving into a new paradigm in the art of medicine. It includes a technologically advanced, patient centered approach that will transform the way we care for each other.
Technology is an important part of these efforts and savings. Even given the potential high cost of technological solutions and Health 2.0 tools, the costs pale in comparison to the $1 million-a-bed cost of hospital construction, let alone hospital staffing and other operating costs."
...
Sunday, September 27, 2009
Patient-Centered Care Awareness
October is Patient-Centered Care Awareness Month, but many do not even know what patient-centered care is or how important this philosophy is to health reform. I have written previously on some aspects of patient-centered care (such as letting a patient see and even make their own chart notes). I suggest you see this post first if you have not read it yet, and especially watch the fun video clip so that you are in the right frame of mind for this discussion. Healthcare has been evolving away from a "disease-centered model" and toward a "patient-centered model." I look forward to the focus on patient-centered care this month.
Although the phrase "patient-centered care" is defined and used in a variety of ways, the essential theme is the importance of delivering healthcare in a manner that works best for patients. In a patient-centered approach to healthcare, providers partner with patients and their family members to identify and satisfy the full range of patient needs and preferences. Organizing the delivery of healthcare around the needs of the patient seems like an obvious approach, but healthcare is a complex system and very little about it is simple. Over 30 years ago when the idea of patient-centered care was born it was swiftly dismissed by all but the most philosophically progressive providers as unrealistic, too expensive and unattainable. To learn more about our own efforts in this area see Courage to be First. Times have certainly changed...
With the introduction of the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) patient experience of care survey, there now exists a standardized tool to evaluate the way care is provided from the patient perspective. HCAHPS examines those aspects of the health care experience that mean the most to patients, including communication with nurses and physicians, cleanliness and noise levels, pain control, and quality of discharge instructions and medication information. Of course, reimbursement methods can drive organizational changes in philosophy and we are now seeing many healthcare systems embrace a patient-centered focus.
The development of a patient-centered medical home provides an enhanced model of primary care in which care teams attend to the multi-faceted needs of patients and provide whole-person comprehensive and coordinated patient-centered care. Since 2006 more than 30 states have initiated projects to advance medical homes in Medicaid and Children's Health Insurance Programs (CHIP), and several states also are driving state-wide transformation. This National Academy of State Health Policy/Commonwealth Fund report provides state policymakers with examples of promising practices and lessons learned.
There is evidence that patient-centered care improves outcomes. The study in the Journal of Family Practice The Impact of Patient-Centered Care on Outcomes found that patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals. There is little doubt that putting the patient at the center of their care makes
If you want to know more about patient-centered care then first go to the Planetree website at http://www.planetree.org/. These websites also provide valuable information on patient-centered practices:
More
Although the phrase "patient-centered care" is defined and used in a variety of ways, the essential theme is the importance of delivering healthcare in a manner that works best for patients. In a patient-centered approach to healthcare, providers partner with patients and their family members to identify and satisfy the full range of patient needs and preferences. Organizing the delivery of healthcare around the needs of the patient seems like an obvious approach, but healthcare is a complex system and very little about it is simple. Over 30 years ago when the idea of patient-centered care was born it was swiftly dismissed by all but the most philosophically progressive providers as unrealistic, too expensive and unattainable. To learn more about our own efforts in this area see Courage to be First. Times have certainly changed...
With the introduction of the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) patient experience of care survey, there now exists a standardized tool to evaluate the way care is provided from the patient perspective. HCAHPS examines those aspects of the health care experience that mean the most to patients, including communication with nurses and physicians, cleanliness and noise levels, pain control, and quality of discharge instructions and medication information. Of course, reimbursement methods can drive organizational changes in philosophy and we are now seeing many healthcare systems embrace a patient-centered focus.
The development of a patient-centered medical home provides an enhanced model of primary care in which care teams attend to the multi-faceted needs of patients and provide whole-person comprehensive and coordinated patient-centered care. Since 2006 more than 30 states have initiated projects to advance medical homes in Medicaid and Children's Health Insurance Programs (CHIP), and several states also are driving state-wide transformation. This National Academy of State Health Policy/Commonwealth Fund report provides state policymakers with examples of promising practices and lessons learned.
There is evidence that patient-centered care improves outcomes. The study in the Journal of Family Practice The Impact of Patient-Centered Care on Outcomes found that patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals. There is little doubt that putting the patient at the center of their care makes
If you want to know more about patient-centered care then first go to the Planetree website at http://www.planetree.org/. These websites also provide valuable information on patient-centered practices:
More
Monday, September 21, 2009
Transparency With Patient Data
I was disturbed to see some of the comments in the recent story on NPR "Doctors Don't Agree on Letting Patients See Notes." The idea that patients should not ordinarily be allowed to see their own chart notes is anathema to me. When Dr Thane says "We may not as accurately describe the mood of the patient, the tenor of the encounter, for fear that we may get someone perhaps already a little angry during the encounter — more so after they log on and read the note that I just finished," betrays a possible unprofessional documentation in the note. Certainly any provider had better be prepared for the chart to be read by the patient, unless there is compelling legal reason not to allow it (such as mental incapacity etc.)
We have for many years allowed patients to not only read their chart, but make their own notes as well. This is core to the Planetree patient-centered philosophy of care.
I am glad to know that this idea is finally gaining traction and hope that those who are afraid of this philosophy will rethink their position. I can assure Dr. Tom Delbanco, of Harvard Medical School, that once you open some daylight into patient's charts there is no going back.
Remember when Elaine needed to see her chart on Seinfeld:
We have for many years allowed patients to not only read their chart, but make their own notes as well. This is core to the Planetree patient-centered philosophy of care.
"The Planetree philosophy stresses that one of the most valuable learning resources available was the patient’s own medical chart. Patients were encouraged to read their charts daily, ask questions and discuss findings, and participate in the decisions affecting their care. Patients were also encouraged to keep written records of their experiences and observations in Patient Progress Notes, which became a permanent part of their medical chart if they so desired."
by Susan Frampton, Ph.D. and Patrick Charmel
I am glad to know that this idea is finally gaining traction and hope that those who are afraid of this philosophy will rethink their position. I can assure Dr. Tom Delbanco, of Harvard Medical School, that once you open some daylight into patient's charts there is no going back.
Remember when Elaine needed to see her chart on Seinfeld:
Subscribe to:
Posts (Atom)
