ClickCare Café

Do Changes in Healthcare Payment Change Attitudes About Collaboration?

Posted by Lawrence Kerr on Thu, Jan 17, 2019 @ 06:00 AM

rawpixel-570908-unsplash (1)The New England Journal of Medicine's Catalyst blog has been doing a really strong job recently -- and their post on value-based care captures the challenging, difficult, and opportunity-filled place we're at in medicine, right now. 

If, as a healthcare provider, you've ever felt like the definition of "value," and how your organization pursues it, is a moving target... or if you've wondered what direction the whole reimbursement system is moving in... then this piece may have some fascinating insights for you, especially as we start 2019.

There has been a remarkable change in how reimbursement happens, even in the last couple of years. Now, a full 25% of healthcare is based on value-based reimbursement, as reported in JAMA (with the other 75% remaining fee-for-service.)

As you're likely aware, this value-based reimbursement is done in two ways: 

  • 1. Capitated Payments. Accountable Care Organizations ACOs use capitated payments (“subscription” per covered life per month)
  • 2.  Bundled payments. One payment, based on the patient's condition, which is split up among whatever services or providers treated that condition.

The mechanics of value-based payment models aren't complicated. But the perceptions of these models, the differing levels of support, and our diverse abilities to meet the models' challenges, all vary dramatically. So JAMA's New Marketplaces Insight Report, exploring the understanding and thoughts of different players in the healthcare system around these shifts, is fascinating.

First and foremost, the report suggests deep ambivalence: "Nearly half (46%) of respondents — who are clinical leaders, clinicians, and executives at U.S.-based organizations that deliver health care — say value-based contracts significantly improve the quality of care, and another 42% say value-based contracts significantly lower the cost of care."  In other words, half of us believe value-based contracts are great for quality and half of us believe that they're very bad for quality. Perhaps not surprisingly, healthcare providers tend to be more skeptical about the model than executives and administrators.

Also, many, across organizations and despite their roles, don't know their organization's stance on value-based care. The authors indicate that respondent answers may show a lack of consensus on what value-based care really means. "While there is broad agreement that value in health care is represented by the balance between the patient-centered outcomes of care achieved with the costs to reach those outcomes, many individuals do not completely understand that concept." For instance, one clinician asserts that "value" isn't really a term that is useful or has a broadly understood meaning: "Right now, [value is] a convenient term that means whatever the speaker wants it to mean.”

Payers and providers are not aligned. And the high rate of salaried employment by healthcare systems adds to the confusion. Many clinicians tend to have the starting point that, "I am morally obligated to my patient, but there is no real contract between the patient and myself." 

Regardless of current perceptions, there also remain practical barriers to full adoption of value-based care models. The primary barriers to the proliferation of value-based models are primarily related to infrastructure, including Information Technology. But regulatory issues, data integration, patient engagement, and others all play a role.

Of course, many of these barriers can be addressed by new tools, like iClickCare. But adoption is an interesting challenge when so many providers are ambivalent about whether value-based care is the right direction... or even how their organization is currently reimbursed.

To me, these shifts emphasize the crucial importance of healthcare collaboration. Wherever you or your organization falls regarding reimbursement, healthcare collaboration has become increasingly critical for doing the care coordination and achieving the outcomes that reimbursement shifts demand. I thought that an executive at a large nonprofit hospital in the South articulated the challenge -- and the opportunity -- of healthcare collaboration well: 

"Physicians had been taught for decades that they were the final arbiter of everything that happens to their patient. When, and until, we change the culture to one of team-based care where the patient belongs to the team, we will continue to struggle with adopting value-based care. As an example, a physician with a length of stay that is 10 days longer than his peer average once told me that the hospital has a length of stay problem because the hospital gets paid a single fee for the entirety of care.”

Clinicians are decreasingly able to bury their heads in the sand when it comes to the big picture of reimbursement. But rising to the challenge of what's to come in healthcare doesn't have to be complicated. Simply working effectively with your colleagues to provide the best, most coordinated, most efficient care possible will ultimately be the best approach -- now, and in the future. 

 

To learn more about how telemedicine can support value-based payment models, download our free Quick Guide: 

ClickCare Quick Guide to Hybrid Store-and-Forward

Tags: healthcare collaboration, telemedicine reimbursement, value based care

3 Simple Ways to Improve Healing in Hospitals (and Length of Stay)

Posted by Lawrence Kerr on Thu, Jan 10, 2019 @ 06:00 AM

luis-melendez-530478-unsplashMany healthcare providers don’t use the healthcare system often. In fact, I’m sure many of us have heard doctors say, “I don’t need to go to the DOCTOR!”

For that reason, sometimes I think we have a limited sense of what it’s like to be a patient.

As a patient in the hospital, we turn our days and nights over to a system that intends to get us to a certain level of recovery and intends to keep us alive. The hospital, per se of course, isn’t always structured to support overall wellness or healing — that’s the job of others in the healthcare system, and of the patients themselves.

But sometimes information will confront us about just how hard a hospital stay can be on the health of a patient -- and we're forced to reconsider our approach.

One common complaint in hospitals is that you can't sleep because of all of the interruptions throughout the night -- vital checks, light, noise, early rounds, blood draws, etc. For many of us, this may sound like a tiny price to play for the crucial monitoring that happens through those hours. And perhaps it is. 

But a recent article in the New York Times reconsiders whether the price truly is small. We all acknowledge the profound value of sleep in our basic functioning and healing: "Short sleep durations are associated with reduced immune function, delirium, hypertension and mood disorders. Hospital conditions, including sleep disruptions, may contribute to 'post-hospital syndrome' — the period of vulnerability to a host of health problems after hospitalization that are not related to the reason for that hospitalization."

There are so many demands in medicine that we’re forced to do things that may not make sense in terms of healing, but are the only way to proceed, working within the structure of the medical system. As the New York Times says, the hospital is "an environment that, all too often, seems set up for everyone else’s convenience but the patient’s.”

As providers who want to truly care for our patients, and in this time of value-based care, these are concerning truths. So what are we to do?

First, I believe that the sooner we can get people home, the better. This is a combination of the efficacy of care within the hospital PLUS an expectation of a high level of support once the patient leaves the hospital. The more we can depend on sophisticated monitoring and care from the home environment, the sooner the patient can get home. Many times, that means we need to be enabling healthcare collaboration across the continuum of care. That way, aides and wound care nurses can tend to patients from where they're most comfortable, but have a moment's access to other providers, as needed.

Second, the more humane, the more holistic, we can make our healing environments, the better. A clinical study showed that even small changes to disruptions to sleep in hospitals cut patients’ sedative use by half. Yes, hospitals are places where we achieve a bare minimum of functioning. But thinking more comprehensively about whether they're also supporting health may be a wise investment for us to make. 

Finally, it's crucial that we let providers make commonsense decisions. Our checklist culture has sometimes reduced errors, but it may have also reduced the commonsense nature of what many of us do. Any nurse has an impeccable gut sense of how she might combine vital checks and blood draws so that no monitoring sensitivity is lost, but the patient is disrupted less frequently. But if she's told she MUST do these things on a set schedule, she begins to override her own sense of what's best for the patient. 

Metrics like Length of Stay can seem challenging or even excessively profit-motivated to consider. But when you think about the patient's experience in the hospital and the intersection of Length of Stay and the patient's quality of healing, it gets clearer how the "right" thing to do is also the "smart" thing to do. 

 

To learn more about how telemedicine can support shorter Length of Stay and improve outcomes, download our Quick Guide: 

ClickCare Quick Guide to Hybrid Store-and-Forward

Tags: hybrid store and forward medical collaboration, decrease length of stay

Is the 2019 Outlook for Nonprofit Hospitals as Bleak as it Appears?

Posted by Lawrence Kerr on Thu, Jan 03, 2019 @ 06:00 AM

brooke-lark-194254-unsplashMoody’s Investors Service came out with their 2019 projections and predictions for nonprofit hospitals.

And unfortunately the summary is: things don’t look great.

Although I don’t put tons of confidence or stock in this type of projection, I do think that the report captures many of the challenges that nonprofit hospitals face.

Fierce Healthcare does a good job summarizing Moody’s report: Moody’s says that nonprofit hospitals are on an “unsustainable path” because of “soft revenue growth, weak inpatient volumes and single-digit reimbursement increases in the coming year.”

Other challenges in 2019 may include lower cashflow, an increase in bad debt, lower inpatient admissions, and pressures like nursing shortages and increasing wages.

So much of healthcare is conservative. We don’t change until we need to. And for many nonprofit hospitals, there has been a consistent tendency to maintain the status quo in an almost superstitious fashion — if I don’t change, then nothing will change around me.

Reports like this demonstrate that things are surely changing around us. Our only choice as healthcare providers, as hospital administrators, and as citizens is whether and how to act proactively so that the things that matter to our organizations and to ourselves can be supported and pursued.

Healthcare is changing around us -- for better and for worse. 2019 will bring new technologies, shifts in reimbursement, demographic changes, and developments in our own practice as healthcare providers. Our goal can't be to not change within that. Our goal has to be to change towards what we envision for ourselves and for our patients. And with the new year here already, I encourage all of us to take the opportunity to reflect on what that might look like this year.

 

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Tags: telehealth, good medicine, telemedicine reimbursement

Why Training New Healthcare Providers Depends on Healthcare Collaboration

Posted by Lawrence Kerr on Thu, Jan 03, 2019 @ 06:00 AM

rawpixel-660721-unsplashOur rallying cry at ClickCare is: access, collaboration, and education. 

Sometimes, people are surprised to hear that medical education is such a core part of what we do.

The reason?  We've always felt that no solution within the medical system can possibly be complete or effective unless it also addresses medical education. Ultimately, there is no separation between excellent medical care and excellent medical education. So the fact that across medicine today, medical education is lagging so far behind innovations in the care itself is deeply concerning. 

As Marc Triola, director of N.Y.U. Langone’s Institute for Innovations in Medical Education said in a recent New York Times article"the gap between medical education and real-world care has 'become a chasm.'" 

I’ll admit that reading this is deeply frustrating. There has been no time in human history when the gap between real-world care and medical education should be smaller. The tools and technology are there. And the need for excellent, powerful, progressive medical education has never been greater. 

This article makes the further point that in many ways, we don’t need MORE healthcare providers (despite the realities of what’s effectively a shortage), we need providers in the right places, doing the right things.

I do agree with that. But where we deviate is the premise that technology should be like a more vivid version of book learning — in which students use virtual reality googles or 3-D simulations to learn.

As we move into a rapidly changing future, our job is not to use technology to make a “fancier” version of how we currently do medical education or medical practice. Our job is to use technology to reframe how we learn, how we teach, and how we care for patients.

It reminds me of a quote from Richard Buckminster Fuller:

“I am enthusiastic over humanity’s extraordinary and sometimes very timely ingenuity. If you are in a shipwreck and all the boats are gone, a piano top buoyant enough to keep you afloat that comes along makes a fortuitous life preserver. But this is not to say that the best way to design a life preserver is in the form of a piano top. I think that we are clinging to a great many piano tops in accepting yesterday’s fortuitous contrivings as constituting the only means for solving a given problem.”

So many of the ways we use technology in medicine are simply using piano tops to solve today's problems. We use telemedicine to replace in-person visits rather than changing how we interact and collaborate as medical providers. And then we use technology to make a more vivid version of the old medical training, rather than reconsidering what's needed today. 

To me, the most interesting and powerful applications of technology and medical education are those that demand that training meet the most challenging aspects of care today. For instance, an inclusion of a more holistic view of the patient’s experience and what it looks like to care for them effectively. One example of this is a program at the Penn State College of Medicine where students serve as “patient navigators” after discharge from the hospital — giving them a sense of the complexities of coordinating care for patients in thoughtful, holistic, and adequate ways. Did that involve any expensive hardware or fancy tech?  No. But it did potentially evolve our students' capacity for working effectively on behalf of our patients. 

Similarly, we're passionate about using iClickCare to treat patients (via telemedicine and healthcare collaboration) but we also deeply believe in iClickCare's ability to support education through collaboration across the continuum of care (learning via the collaboration in each case) as well as the archiving of the collaboration process for each case, so that providers and students learn from key cases, even if they weren't involved at the time. 

Each and every healthcare provider has the responsibility of caring for our patients. But we also have the responsibility of training and leading the next generation of providers -- without that, our efforts don't build upon themselves.

See how telemedicine can help improve medical education by trying iClickCare in your practice and teaching:

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Tags: hybrid store and forward medical collaboration, medical education

Healthcare Mergers and Consolidations Seem Efficient But May Cost More

Posted by Lawrence Kerr on Thu, Dec 27, 2018 @ 09:50 AM

sean-pollock-203658-unsplashThere has certainly been a trend in medicine towards centralization, silo-ization and consolidation.

I think that you can see it best in the reverence many patients have for major hospital systems. When someone has a challenging diagnosis, the first thought is always to find the biggest, most well-known hospital system, and pursue “the best” care, there.

But a systematic study I read last week upended all of that, showing that mergers and consolidations may actually increase costs and prices.

I believe there is also a somewhat superstitious sense within the medical community that small, community-based approaches may be “nice” but that they are inherently less efficient and more costly than consolidated, centralized approaches. When I was in private practice, there was always an underlying understanding that it may be quaint to practice in a small, community-based medical group but that it would be more efficient -- in cost savings to us and price savings to the patient -- to practice within a hospital system instead. 

This never sat well with me, even though I could hope for the myriad efficiencies that streamlined communication and thoughtful care were creating. So I was curious to read this study that looked at the effect of hospital mergers 2010-2013 in 25 metropolitan areas. 

Overall, the study showed that prices in most areas increased between 11% and 54% for years after the merger, in most areas. And, “prices rise even more steeply when these large hospital systems buy doctors’ groups, according to Richard Scheffler, director of the Petris Center. It's hard to tell from the data whether the price increases come from increased costs or from decreased competition (meaning higher prices due to market distortions.) 

Consolidations don't seem to be slowing. And the biggest of the bunch -- for instance Dignity Health and Catholic Health Initiatives, have 139 hospitals in 28 states and are truly staggering in size. As these consolidations happen, prices rise consistently and often, hospital access goes down as patients are forced to travel farther for care.

Truth be told, I don't know enough about the vagaries of incentives or regulations at the macroeconomic level to suggest a solution. But I do think that the phenomena themselves, as described by the study, suggest the value of diversity in our healthcare system. 

Bigger and more centralized is not always better. The way to achieve efficiency and scale is by more types of providers working more closely together -- across lines of specialty, training, geography, and time -- not by mergers. Yes, a diverse coalition of the small -- rather than a forcing of everyone to become big -- requires more tools and sophistication. But I believe that healthcare collaboration is a better route to efficiency and access than every hospital becoming a mega-hospital. 

 

To learn more about alternatives to consolidation and mergers, download our Quick Guide to telemedicine: 

ClickCare Quick Guide to Hybrid Store-and-Forward

 

Tags: heatlhcare collaboration, value based care, handoffs

Is a Trip to Paris as Effective as More Medical Treatment?

Posted by Lawrence Kerr on Thu, Dec 20, 2018 @ 12:41 PM

zulmaury-saavedra-654180-unsplashAs healthcare providers, every interaction we have with patients is potentially life and death.

So it’s easy to write off non-medical aspects of our patients life as “fluff” or “soft stuff” or say “we can worry about that once we’ve beaten this.”

For us, though, we’ve found in decades of providing care for our patients, that these “quality of life” things are far from fluff. These elements of patients' lives can often be more impactful to their overall recovery and healing than any medicine or intervention. So a recent study confirming just that was both validating and fascinating. 

When a teenage swimmer comes to us with a limp that might be a potential neurological problem, making sure that she’s able to go to swim practice rather than bouncing from appointment to appointment is a crucial part of ensuring her speedy recovery. Getting an older man home to recover from heart surgery where he can also garden (rather than lie in a hospital bed) is simply a better path to healing.

These are all reasons that iClickCare exists. Telemedicine-based healthcare collaboration allows providers to collaborate on behalf of the patient, asynchronously, and across the continuum of care. That means that patients spend less time in exam rooms and waiting rooms and hospital rooms. And more time in the spaces and places that are nourishing and healing to them (like a swim practice or a garden.) 

Along similar lines, a recent study really validated this approach. The study's lead author is Dr. Anup Patel of Nationwide Children’s Hospital. He is a pediatric neurologist who focuses on the severest of epilepsy patients. He had many patients over the years who received a "wish" through the Make a Wish Foundation -- choosing a wishes like a trip to Paris, meeting a celebrity, or a day in their dream profession. And anecdotally, he found that patients who received wishes from Make a Wish did better, got better results, and were happier for long after the wish. So Dr. Patel decided to do a real study. 

As Fierce Healthcare reports: "The study compared patients who received or did not receive a wish and associated impact on healthcare utilization and costs across two years. Looking at the electronic health record database from 2011 to 2016, 496 Nationwide Children’s Hospital patients received a wish. These were matched to the same number of a control group based on age, gender, disease category and disease complexity. The average cost of a granted "wish" is a little more than $10,000. By his study's calculation, there was a decrease in the cost of care of about $10,130 two years after a wish is granted."

So the wishes saved more in medical expenses than they cost. Plus, patients who were granted a wish experienced fewer hospital admissions and fewer trips to the emergency room. So far beyond the joy of the experience, patients were measurably healthier, and had better outcomes. 

I really respect Dr. Patel's curiosity and courage in exploring the effect of these wishes on his patients -- and his rigor in measuring the effects. This kind of holistic perspective -- combining qualitative concerns with quantitative measures -- is such a powerful way of advancing medicine. 

 

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What Factors Influence Telemedicine Adoption Across States?

Posted by Lawrence Kerr on Thu, Dec 13, 2018 @ 09:12 AM

rawpixel-586687-unsplashTelemedicine is not a new technology.

In fact, we’ve been doing telemedicine for almost 20 years at ClickCare. As you may know, we started by pioneering in a School-Based Health program at local underserved elementary schools. That program used newer technology — including some digital cameras — but really, the success of it was related to the approach and openness of the providers, patients, and families involved.

Because the school nurses and the pediatricians were so oriented towards caring for their young patients as well and as holistically as possible, they were open to trying new approaches. As participants saw the success of the program, it became broader and more organizationally supported. And honestly, at no point was there any conversation around reimbursement or policy — it was just one more way they cared for their patients.

All of the providers that use iClickCare today approach it similarly. While telemedicine is increasingly common, it’s certainly not the default. And so providers or hospitals that incorporate the tool do so as a conscious choice. Reimbursement improves; political and organizational support expands; but through it all, providers carry on with the tools and approaches they think will help their patients the most.

I was interested to read a report in JAMA, however, and extended in Fierce Healthcare, looking at how telemedicine use is expanding (or, in some cases, not), and how reimbursement laws relate to these adoption phenomena. Parity laws demand that insurer reimbursement be the same for telemedicine-based care as for in-person care. These laws have been adopted in 64% of US states. In confluence with this, there was a significant uptick in telemedicine usage among primary care physicians between 2015 and 2017. For more rural areas, mental health services seemed to be higher usage than other specialities. While in urban areas, primary care telehealth was more common.

This is all in line with the expansion of both telemedicine and reimbursement that we’ve seen. Parity laws demand that insurer reimbursement be the same for telemedicine-based care as for in-person care. That said, one interesting fact stood out: “the data showed a negative association with states that enacted comprehensive parity laws mandating reimbursement for the services.”  Perhaps that is because those states struggled the most with adoption in the first place — but either way, it’s clear that adoption “from the grassroots” may be more effective than approaches that aim to implement telemedicine starting at the policy level.

With any shift in practice, there is always a combination of technological, personal, psychological, and societal factors that need to come together for the technology to be incorporated into use.

For instance, simply inventing the telephone doesn’t create a culture that calls your friends. A combination of phone lines, social change, and early adopters combine with the new invention to lead to a society that talks on the phone.

On the one hand, telemedicine is becoming increasingly widespread, generally. There is increasing consensus that telemedicine can contain costs, increase access, and cut healthcare provider burnout. It’s not surprising that so many providers, patients, and payers are incorporating the technology into how they “do medicine.”  On the other hand, telemedicine implementation isn’t a matter of policy or a “snap of the fingers.”

Ultimately, telemedicine adoption must come from providers and patients. There is no way to legislate or demand creative ways of caring for our patients.

Learn more about how to implement telemedicine in your organization, economically and quickly, with our Quick Guide to Hybrid Store-and-Forward Telemedicine: 

ClickCare Quick Guide to Hybrid Store-and-Forward

Tags: telehealth, hybrid store and forward medical collaboration, regulatory issues

Why Medical Collaboration Can Help Us Lead With Our Values

Posted by Lawrence Kerr on Wed, Dec 05, 2018 @ 09:41 AM

vidar-nordli-mathisen-537587-unsplashIn our community, there are two nonprofit community hospitals and one Catholic hospital. All are excellent. Each has slightly different founding values and ways of operating. All three have a strong heart and soul, which has been more or less apparent at different times depending on leadership.

So a recent article exploring the shift in how Catholic Hospitals have approached their values and leadership — and the effect that can have — certainly caught my eye.

Catholic Hospitals used to be run, of course, by nuns. Increasingly, however, as the Fierce Healthcare article describes, “Catholic hospitals are much more likely to be run by lay executives who don’t serve as a human embodiment of religious roots.”

There may be multiple positive aspects of this shift. Perhaps the hospitals are able to serve a broader base of people with a greater diversity of religious backgrounds or values. Perhaps the lay leadership is stronger in some technical aspects of running or managing the hospitals. But the author of this article points out that the shift away from hospitals’ original values “can actually hurt their bottom line, as Catholic hospitals lose the loyalty of community members who sense an erosion of the values that were long integrated into their care.”

In other words, although it may seem that the immediate effect is one of broadening and strengthening, there may be side effects — as of any strong medicine — that outweigh the positives. As the author concludes, we in medicine are in a unique place that is at the intersection of art, science, morality, and human caring. Indeed, “hospitals are seen as more than just a business – they are often seen a reflection of the overall health of a community.”

I don’t have a detailed understanding of the specifics of Catholic hospitals and how these shifts to lay leadership have affected them. That said, I have found on a personal, business, and medical level — that when you dilute or don’t lead with your values, it may seem practical but leads to negative consequences.

Collaboration is about declaring to ourselves and our colleagues that we have a unique perspective, unique skills, and unique values as individual providers. We’re not a generic “healthcare provider” that can be swapped in for any other provider. If that were the case, any provider could provide the same care as any other — and collaboration would be far from necessary.

Let there be no mistaking it: when we lead with our values, and care for patients from our unique set of strengths, weaknesses, and values — we are more interdependent with our colleagues and we end up with a more unique role in the process. For providers who want to see themselves as invincible, this can be uncomfortable. But, as with the example of the hospitals, there may be immediate, short term benefits to diluting our values and trying to be all things to all people — but ultimately, it results in weaker care.

In fact, I think that is one reason that iClickCare, and telemedicine-based medical collaboration in general, is so effective. When we are able to collaborate, to reflect on cases, and to lead (and treat patients) with our values, we get better results. As the article author emphasizes, “There’s benefit in continuing to cultivate the essence of local hospital’s unique personality and roots, even as the benefits of system affiliation are stressed.”

It takes courage to practice medicine from your own unique perspective and strengths, rather than from an imaginary “generic” place. But the rewards are great — and so is the care.

For more stories of courage, medicine, and medical collaboration, download our Quick Guide to Medical Collaboration:

ClickCare Quick Guide to Medical Collaboration

Tags: hybrid store and forward medical collaboration, medical collaboration software, good medicine

Is Gun Violence a Public Health Issue Needing Medical Collaboration?

Posted by Lawrence Kerr on Thu, Nov 29, 2018 @ 06:00 AM

david-leveque-544057-unsplash

After declining steadily through the early 2010s, gun violence has been rising in the US. Mass shootings, while a very small percentage of total gun deaths, have also risen significantly in the past few years — thus the reason that it feels like we hear about a new shooting every week. Of course, the overall numerical significance of gun deaths may not be as sizable as other causes of death -- but gun deaths remain a killer in our country.

For these reasons, gun violence is sometimes seen as a public health issue. Although not an “unpreventable biological disease,” it is a killer and a factor in the well-being of our citizens. Similar to the opioid epidemic, gun deaths have social, public health, political, and behavioral dimensions. So it makes sense that doctors may have perspectives and concerns about gun violence, especially trauma or ER doctors who are literally on the front lines of battling to save patients who have suffered from a gunshot wound. (That said, the overall deaths from gun violence each year are tiny compared to many other public health problems.)

But a recent kerfuffle highlighted how difficult this topic can be to broach.

As is highlighted in a recent New York Times article, Bronx doctor, Dr. Marianne Haughey was outraged when the National Rifle Associated tweeted: "Someone should tell self-important anti-gun doctors to stay in their lane.”

She replied, "I have cared for victims of gun violence for the past 25 years. THAT must be MY lane." 

The politics and practicalities of gun control and mitigation of gun violence are beyond my sphere of expertise. And the analysis of the relative significance of gun deaths relative to other causes of death is a matter of real research to understand -- not something to address flippantly or scandalize.

But regardless of those more specific questions, for me, the conversation brought up an important question -- what does it mean for a doctor to "stay in their lane"?

What is our lane as doctors, generally, and as individual doctors?

Does our “lane”…

  • End after the last stitch is sewn, as surgeons, or does it extend to stopping by to check on the patient post-surgery?
  • End after we refer a patient to a specialist, or does it extend to following up on their care?
  • Include the societal, social, behavioral, and economic determinants of health?
  • Necessitate medical collaboration, or is seeing a patient during the visit the only job we have?
  • End at the end of our shift?

The answers to these questions have evolved for physicians and healthcare providers over time. And the truth is that there are no right answers. There do have to be boundaries to our sphere of influence as doctors -- both to remain within our expertise and to maintain sanity and efficiency. 

But I think that as a healthcare culture, we've drawn our "lane lines" too narrowly. I do believe that doctors have an important voice when it comes to questions of gun violence. I do believe that surgeons have a responsibility to care for patients long after the surgery is complete. And I believe that medical collaboration is a bare minimum requirement for adequate care. 

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Tags: good medicine, medical collaboration tool

Are Medical Mistakes Linked to a Lack of Medical Collaboration?

Posted by Lawrence Kerr on Tue, Nov 27, 2018 @ 06:00 AM

roman-kraft-266787-unsplashIn a recent New York Times article, Dr. Peskin tells the story of one of her patients — Shirley.

The first time that Dr. Peskin saw Shirley, she had been taking shots on a daily basis to deal with her diagnosis of Multiple Sclerosis.

5 months later, Dr. Peskin saw her again because she had now suffered anaphylaxis from the shots. In the process of treating the anaphylaxis, another doctor ended up reviewing Shirley’s history and concluded that she didn’t have MS at all — indicating that the decades-long course of daily shots were actually unnecessary.

In other words, Shirley’s first doctor made an incorrect diagnosis; that diagnosis was confirmed by a second doctor; and a it wasn’t until a third doctor was involved that the mistake was revealed.

This story certainly isn’t unique. In fact, mistakes are often revealed at the junction point between two doctors — whether it’s during a handoff or because care has been taken up with a new doctor for a different reason.

 

To me, there are three important findings that relate to this story:

  • Mistakes must be part of our medical experience.
    The entire structure of our medical system and practice treats mistakes as an unpardonable, inexcusable part of care. That means that, as Dr. Peskin explains, doctors are left to deal with the intellectual and emotional aftermath of making a mistake on their own. And, I think, learnings from mistakes are limited. Far better would be to incorporate a thoughtful exploration of our mistakes into our practice — in a way that doesn’t necessarily make anyone “wrong” for having made the mistake in the first place. This is one crucial reason that all ClickCare cases are automatically archived and searchable for teaching and reflection.
  • The more we collaborate, the better we do.
    If you collaborate, you don’t need to wait until a mistake is found “after the fact” — another set of eyes (or two or six) can help us make better decisions and diagnoses in the moment.
  • Handoffs are not collaboration.
    It’s important to note that Shirley would likely have received more thoughtful, appropriate care if her three doctors had been able to work together, sharing perspectives. This type of collaboration creates far better, more sophisticated care than simply bouncing the patient between providers. It’s possible that her original doctor had important insights about her that informed the diagnosis of MS — and rather than reversing the original diagnosis, perhaps the final doctor would effect the change by integration or interpolation, while engaging together about the care.

 

Shirley's case didn't end badly, and all of her doctors had been working hard to provide the best care possible. But we believe that a better way is possible, easy, and doable -- if doctors have the right tools and the right mental framework. Doctors don't have to "go it alone" and be infallible -- they can collaborate and they can learn from their mistakes. 

 

ClickCare Quick Guide to Hybrid Store-and-Forward

Tags: medical mistakes, medical collaboration tool

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