Why is Healthcare Broken?
Why is healthcare broken? There is a multitude of reasons, but the poor delivery of care is often the result of ignorance. Yes, for years quality experts and specialists from all medical specialties have worked on guidelines that are based on scientific evidence. The problem is will physicians adapt them? Will hospital and hospital systems ensure compliance with the guidelines?
Let me give an illustration that recently appeared in DHealthcare Daily where the CEO of Methodist Health System was interviewed. The CEO is quoted as saying “So last year we spent a lot of hours working on a condition called sepsis, which has a very high mortality. It’s lethal in many cases, and it’s lethal not only in the elderly but the young as well. So our learning in that, learning the early symptoms and the early interventions that need to take place, and how the key is early intervention, and the impact that has had on the way we practice across Methodist as it relates to sepsis is dramatically different today than it was 12 months ago. And the impact, well, it’s a life saver. There’s no question about it. We were average in that area, I would say, among hospitals in America. Today I would say we’re in the top decile.”
What is disturbing is that sepsis had been around for years. The fact that the Society of Critical Care Medicine along with other professional societies published scientific guidelines on the recognition and treatment of sepsis back in 2002. Why 14 years later are healthcare professionals suddenly realizing this is a major problem that affects almost 800,000 patients a year? Why is the dissemination and utilization of sound medical evidence not being implemented immediately?
The above example is one of many that may be attributed of hospitals not having the expertise of quality programs or specialists in certain areas of medicine. It may also be the result of physicians either not accepting guidelines or not paying attention. Telemedicine may have a very significant impact on improving quality. Telemedicine may very well be the conduit to provide intensivist and infectious disease expertise to hospitals that lack these specialties. The same services may enhance both accessibility and speed to obtain highly efficient treatment modalities. There is growing evidence to suggest that remote care by distant intensivists and infectious disease physicians provide a significant quality benefit to patients often unable, because of geography, not have access to these providers.
Certain diseases that affect larger portions of our population often have associated evidence-based guidelines for physicians. It is up to hospital leadership to ensure compliance. When expertise is needed for patients that are complex, then telemedicine is certainly an alternative that must be utilized.
One story which never made the mainstream press is the humanitarian gesture of a group of ICU Telemedicine specialists providing civilian ICU care in war-torn Syria. Reported in the February issue of the Annals of American Thoracic Surgery, a network of approximately 20 participating intensivists was providing clinical decision support 24 hours per day to five civilian ICUs in Syria. The program utilized inexpensive, off-the-shelf video cameras, free social media applications, and a volunteer network of Arabic-speaking intensivists in North America and Europe. Launched in 2012 and within 1 year, 90 patients per month in three ICUs were receiving tele-ICU services. What would normally take numerous committee meetings including budgetary constraints was done on an all volunteer basis at a much lower than expected cost.
The program is implementing a cloud-based electronic medical record for physician documentation and a medication administration record for nurses. There are virtual chat rooms for patient rounds, radiology review, and trainee teaching. The early success of the program shows how a small number of committed physicians can use inexpensive equipment spawned by the Internet revolution to support from afar civilian health care delivery in a high-conflict country.
The critical care community and the world will be waiting to see data from this extraordinary and courageous endeavor. Congratulations to Drs. Moughrabieh and Weinert from the University of Minnesota Medical School, Minneapolis, Minnesota.
Inconsistencies with brain death criteria: telemedicine to help?
Is there a role for telemedicine in the determination of brain death? An article in JAMA Neurology December 28th included 52 organ-procurement organizations obtaining brain death policies from 492 qualified hospitals across the United States. The researchers evaluated the policies based upon:
- who is qualified to perform the determination of brain death,
- what are the necessary prerequisites for testing,
- details of the clinical examination,
- details of apnea testing, and
- details of ancillary testing.
There remained significant variability across all 5 categories of data, such as excluding the absence of hypotension (276 of 491 policies [56.2%]) and hypothermia (181 of 228 policies [79.4%]), specifying all aspects of the clinical examination and apnea testing, and specifying appropriate ancillary tests and how they were to be performed.
Additionally the study revealed:
33.1% required specific expertise in neurology or neurosurgery for the health care professional who determines brain death,
- 43.1% stipulated that an attending physician determine brain death;
- 150 policies did not mention who could perform such determination.
CONCLUSION: Hospital policies in the United States for the determination of brain death are still widely variable and not fully congruent with contemporary practice parameters. Hospitals should be encouraged to implement the 2010 AAN guidelines to ensure 100% accurate and appropriate determination of brain death.
COMMENT: ROLE OF TELEMEDICINE?
The issue is what is the role of telemedicine, if any, in the determination of brain death? At first glance, one would think that the determination of brain death is such an emotionally challenging procedure that the presence of a physician would be expected. Working closely with families which at times requires the holding of the hand, the provision of a tissue or reassurance is an important aspect of providing care by both physicians and nurses. Can this be achieved remotely? One might easily agree that in hospitals that do not have a physician available, telemedicine as a proxy might be better than no physician presence. On the other hand, an Emergency Medicine physician who is trained in this evaluation could serve in the capacity of providing the proper assessment. The telemedicine neurologist or intensivist promote the utilization of the AAN guidelines. Most importantly as the study has shown, there is no reason why all hospital brain death policies should not be in compliance with the 2010 AAN guidelines. In the end, telemedicine should serve as a clinical service that augments on site physicians and brain death procedures might be the alternative and not the preferred solution.
State medical licensure for telemedicine is discussed in the April issue of Telemedicine and eHealth, by Drs. Hunter, Weinstein, and Krupinski. One of the authors in fact sat on the Arizona state medical board so a unique perspective is presented.
While progress is forthcoming for state reciprocity through an Interstate Compact initiated by the Federation of State Medical Boards (FSMB), licensure process may be slightly easier but the costs for licensing will remain.
Here are some key points:
- Article X of the U.S. Constitution states that individual states have the authority to insure health, safety, and welfare for their citizens. This explains why there is no universal medical license in the United States.
- There is tremendous variability among the states as far as requirements. See Rogove et. al. in this same journal
- The major exception to state requirements is through the federal government, which allows physicians to possess only one state license to practice at medical facilities such as the VA system.
- One of the biggest barriers to reciprocity is having a history of a malpractice suit. This will result in a major and lengthy investigation, often resulting in approval for most physicians.
- Interstate Compacts will not change the state’s existing medical practice act.
- The practice of medicine is defined in the state in which the patient is present and not the state where the physician resides.
- The significant challenges include:
- When is the physician-patient relationship established? Some states are now creating chaos by requiring the relationship must begin with a fact-to-face encounter.
- Assuring patient privacy.
- Limiting physician prescribing to certain classes and types of medication.
A process that has been in existence for 100 years is up for a remake to help enter the twenty first century. We have reached a cautious but optimistic time for pushing telemedicine towards reaching its important position in healthcare delivery.
Telemedicine can have a significant impact upon the existing racial disparity of healthcare access through home monitoring of hypertensive patients. It is a well know fact that hypertension and hypertensive heart disease is predominant among the African-American population, especially males. It is also known that access to care for all communities has been less than optimal.
In a recent review in Curr Hypertens Rep there was evidence of better compliance, very good acceptance by patients, and a lower utilization of high cost facilities such as the emergency department. The review also concludes that it is not only hypertension but also chronic heart disease including CHF and Diabetes that also benefit from close patient monitoring. While the review has demonstrated some excellent outcomes, the authors are the first to admit more studies are needed.
The study begins the discussion where patients with hypertension now have access to healthcare professionals who can monitor and advise patients in a convenient and cost-effective model that is all inclusive. When healthcare economists continue to look for value, this solution is simple, easy to implement, and can result in millions of dollars in saving annually.
Just fast tracked on Telemedicine and eHealth’s website is an important survey of professional license companies that deal with over 1,000 applicants a year to practice telemedicine in multiple states. Dr. Herb Rogove and co-authors sent surveys to participants who have experience with telemedicine as well as on site practices in multiple states throughout the continental United States and its territories. Here are the key elements of this article:
- Fifty four percent of the respondents felt it was a prolonged process because of variable requirements and deficiencies within the medical board office.
- Difficulties were centered around failure to respond to questions, lack of cooperation, inability to use FCVS, lack of a uniform process and consistency across all medical boards.
- Lost documentation occurred and 79% had to resubmit documents.
- The most reasonable states (reasonable defined as responsive, cooperative, willingness to expedite, and knowledge) were identified as Oregon, Wyoming, Pennsylvania, and Montana.
- The respondents felt the most difficult states to deal with were: California, Texas, Arkansas, and Massachusetts.
- The shortest time to obtain a medical licenses was felt by respondents to be Indiana, Arizona, and Virginia.
- The longest time to obtain a medical license was thought to be California, Illinois, and Texas.
- Variability of requirements, which is set by each state, was considered to be a major issue.
- Reciprocity for all states was a major suggestion by those who were surveyed.
This survey illustrated that medical license portability continues to be a major and time consuming barrier for expanding telemedicine’s rapid deployment to areas in need of physicians. Despite the recent compact by the Federation of State Medical Boards, the process may be streamlined but lacks the major impact of full reciprocity of all states.
from: Healthcare DIVE
- The House Energy and Commerce Committee released a “discussion document” seeking feedback on its 21st Century Cures initiative, which is filled with a number of healthcare IT proposals.
- Key provisions include one that would create a process at the US Food and Drug Administration to expedite the review of “breakthrough” medical devices; another that would require that data be shared by those receiving grants from the National Institutes of Health; and a third to advance telemedicine opportunities for Medicare beneficiaries.
- However, while suggestions within the provision for improving Medicare’s telehealth policy are broadly considered to be a step in the right direction, a letter from the American Hospital Association to committee chairman Rep. Fred Upton (R-MI) says they don’t go far enough.
The “Advancing Telehealth Opportunities in Medicare” proposal calls on HHS to draw up a methodology to expand coverage and payment for telehealth services nationally. There are limitations to the provision, however. It will only apply if the Centers for Medicare and Medicaid Services find that those telehealth services “would reduce [or would not result in any increase in] net program spending under this title.”
According to the AHA, the proposal does not address technology limitations within Medicare itself, or how remote monitoring would be funded.
“We also are concerned that the requirement for the Medicare actuary to certify telehealth cost neutrality for specific services would be hard for HHS to operationalize, and would add a time consuming step when technology is advancing at a rapid pace,” the AHA wrote.
Teladoc Inc. of Dallas is the latest telemedicine provider to be shut out of Arkansas because of Arkansas State Medical Board rules involving physician-patient relationships.
“The board has traditionally defined the establishment of a doctor-patient relationship as: an in-person history and a physical,” board attorney Kevin O’Dwyer told Arkansas Business recently.
And without that, the telemedicine doctors — unless they’ve seen a patient in person — can’t treat Arkansans, making Arkansas one of the handful of states that don’t allow telemedicine companies in their state.
O’Dwyer said the only reason the board has the requirement is to protect the patient.
Still, O’Dwyer said the board discusses the issue “regularly. … We haven’t seen a model from any of these companies that would satisfy, in the board’s opinion, the regulation.”
Teladoc had been offering the service in Arkansas since 2008, its CEO, Jason Gorevic, said. But recently, the board “made it clear that they would take action against physicians who were practicing telemedicine,” Gorevic said.
Teladoc suspended its service in November, pending approval from the board. It has 70,000 members in Arkansas.
“They have, unfortunately, declined our offer to come in and present,” Gorevic said. “In the meantime, there are many other parties in the state who are interested in telemedicine and see its promise for reducing costs, improving quality of care and improving access to care.”
Teladoc offers services across the country except in Arkansas and Idaho, where it also recently suspended its service because of its medical board rules. But Gorevic said he hopes that Teladoc will be allowed to practice in Idaho soon, thanks to pending legislation.
Teladoc sells its services primarily to employers and health plans to use as part of their benefits packages. The members then have full-time access to a national network of board-certified, state-licensed physicians who can be connected to a patient within about eight minutes, Gorevic said.
The patient can decide to interact with the doctor by a video or phone consultation. Or a patient can send a photo of the ailment to the doctor.
Comments: Since 2008 and now the Board is weighing in? Refusing to meet with Teladoc? Patients are free to use to service or NOT? What kind of message is the Arkansas state medical board telling their citizens?
>PRWEB.COM Newswire(PRWEB) December 19, 2014
With the rapidly evolving healthcare landscape, Mediaplanet has joined forces with the American Medical Association, Sir Richard Branson and many more to educate readers on the plethora of groundbreaking innovations that are available in the industry to reclaim their health.
The print component of “The Future of Healthcare” will be distributed within this weekend’s edition of USA Today, in New York, Chicago, Los Angeles, Minneapolis, Washington D.C., Baltimore, and San Francisco, with a total circulation of approximately 450,000 copies and an estimated readership of 1.3 million. The digital component is being distributed nationally through a vast social media strategy and across a network of top news sites and partner outlets. To explore the digital version of the campaign, click here.
Investing mogul and entrepreneur Sir Richard Branson is featured on the cover of both the print and digital editions. In Mediaplanet’s exclusive interview with the icon, we discuss why he believes telemedicine is the future of healthcare. “Being smarter with data and technology will improve healthcare,” said Sir Richard. He goes on to discuss just how beneficial these advancements can be. “Doctors will be able to provide better care and patients can receive faster treatment, all at a lower cost to the industry.”
This campaign was made possible with the support of the American Medical Association, American Telemedicine Association, Kaiser Permanente, Sir Richard Branson, American Nurses Association, G. Duncan Finlay, Dr. Jess Lonner, Konica Minolta, Alive Science, Vidyo, Virtumedix, OnBase by Hyland, and Blue Belt Technologies!
Mediaplanet is the leading independent publisher of content-marketing campaigns covering a variety of topics and industries. We turn consumer interest into action by providing readers with motivational editorial, pairing it with relevant advertisers, and distributing it within top newspapers and online platforms around the world.
According to MedCity News:
Dr. Ezekiel Emanuel, a healthcare economist and bioethicist at University of Pennsylvania and an Affordable Care Act architect presented a pretty dramatic vision of how the hospital landscape and healthcare delivery will change in response to healthcare reform. He also shared some insights into the law’s design at New York eHealth’s Digital Health Conference this week.
20 percent fewer hospitals Emanuel estimated that 1,000 acute care hospitals will close and be converted into outpatient facilities and physician offices. Top tier hospitals will focus on complex procedures such as fetal surgery and organ transplants.The emphasis will be on patients recovering from home and using telemedicine and home visits for follow-up care.
Leaner hospitals He also pointed out that hospitals needed to take a hard look at operational improvement to make them more efficient and less costly to run.
Telemedicine as a critical component He pointed out that telemedicine will be critical to achieving goals of ACA because it will expand the ability of physicians to treat more people beyond traditional office hours. It will also help address the physician shortfall.
Behind the scenes of ACA Emanuel shared some insights on developing ACA. He said that he wanted a 10 percent readmission penalty on Medicare reimbursement for hospitals instead of the agreed upon 1 percent to 3 percent because it would have made more of a difference to hospitals.
VIP care for patients with chronic conditions and mentally ill The big goal is to reduce healthcare costs for the people who tend to use it the most by devoting more resources to helping people with multiple chronic conditions manage their condition.
Digital Health To control healthcare costs, one element will involve mining claims data and electronic medical records to micromanage doctors to ensure that they are adhering to best practice guidelines and not over ordering tests.
Emanuel dismissed the defense that doctors were frequently driven by fear of malpractice suits to over order tests rather than medical judgement. A report last month found that two states with malpractice reform saw no change in the number of medical tests being ordered.