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Peril to patients seen in EHR firms’ ‘gag clauses’

September 13, 2015by Robert Whitcomb in Uncategorized tagged , , , , , , ,

 

gag

Politico reports that that some of the biggest electronic health record companies have inserted “gag clauses” in their taxpayer-subsidized contracts. These clauses effectively bar healthcare providers from “talking about glitches that slow their work and potentially jeopardize patients.”

The news service reports that “Vendors say such restrictions target only breaches of intellectual property and are invoked rarely. But doctors, researchers and members of Congress contend they stifle important discussions, including disclosures that problems exist. In some cases, they say, the software’s faults can have lethal results, misleading doctors and nurses who rely upon it for critical information in life-or-death situations.”

The article says that the  Office of the National Coordinator for Health IT (ONC) and the Centers for Medicare and Medicaid Services, which are responsible for the EHR subsidy program, have ”done little about the clauses, though providers and researchers have been grumbling about them since the 2011 Institute of Medicine report warning that ‘[t]hese types of contractual restrictions limit transparency, which significantly contributes to the gaps in knowledge of health IT–related patient safety risks.”’

 

Revolutionize clinical-practice guidelines?

August 5, 2015by Robert Whitcomb in Uncategorized tagged ,

 

An article in JAMA poses the question:

Specialty society clinical practice guidelines: Time for Evolution or Revolution?

“The IOM  {Institute of Medicine} has strongly suggested that the current approach to development of CPGs {clinical practice guidelines} is flawed and fundamentally needs a new approach. Despite repetitive calls from many stakeholders for other entities to develop CPGs, to date, little has changed in the way most current CPGs are developed. Because of the many challenges in the current process, it will be difficult, if not impossible, for specialty societies to completely redirect the CPG development process to be effectively led by other entities.

“Therefore, to create CPGs that the public trusts, that clinicians and patients can readily implement, and for which compliance can be easily measured, the CPG development process should continue to be led by specialty societies but with a new model that integrates other stakeholders, including patients. Specialty societies will need to use a consortium process in which authors are not just from the specialty society ranks and the focus is on concise, rigorously evidence-based, highly practical, implementation- and measurement-focused CPGs with COI transparency. This approach could be disseminated broadly and adopted so that specialty society CPGs can be effectively used in critical efforts to improve the quality and safety of care and reduce cost.”

Strategies for faster and better care

July 31, 2015by Robert Whitcomb in Uncategorized tagged ,

speed

A new Institute of Medicine report says that hospitals  can deliver services much faster, and with quality improvements, without  adding much to costs.

Among the recommended strategies:

  • Matching supply and demand through continuing evaluation.
  • Immediately determining  need when the patient inquires about services.
  • Learning when the patient wants to come in, and what kind of care is desired.
  • Offering need-tailored, technology-enabled alternatives to clinic visits, when appropriate.
  • Formal planning for patient surges.
  • Constantly assessing changing circumstances.

 

 

 

 

Hospitals need systems engineering to reduce waits

July 6, 2015by Robert Whitcomb in Uncategorized tagged ,

 

wait

Marty Stempniak, writing for Hospitals & Health Networks, comments on an Institute of Medicine report on those exasperating healthcare wait times, citing his own hospital ER misadventure.

He writes: “{E}ven in this new world of consumer-focused, value-based healthcare, patients are still waiting for hours on end to receive treatment. A new study from the Institute of Medicine, released last week, found that wait times vary dramatically across the healthcare sector, with patients experiencing a gap of anywhere between a few hours to a few months to get an appointment with a doctor.”

Gary Kaplan, who chaired  the committee that produced the report and is CEO of Virginia Mason Health System in Washington state, urges healthcare organizations to look to  industries with rigorous systems approaches — such as manufacturing and hospitality — to better deliver care — when and where patients want it.

“{I}t does require us to be willing to use these systems-engineering principles to understand supply and demand, and then design our systems to have adequate capacity for true demand of services,” he said.

 

Mr.  Stempniak summarizes the IOM report’s  six principles to address this problem:

  1. “Supply-demand matching through formal ongoing evaluation.
  2. “Immediate engagement and exploration of patient concerns at the time of inquiry.
  3. “Patient preference on timing and nature of care invited at the time of inquiry.
  4. “Need-tailored care with reliable, acceptable alternatives to doctor visits (i.e., telehealth and electronic consultations).
  5. “Surge contingencies in place to ensure timely accommodation of needs.
  6. “Continuous assessment of changing circumstances in each care setting.”

 

 

15 core metrics for health

May 1, 2015by Robert Whitcomb in Uncategorized tagged

 

An Institute of Medicine committee has identified  15 measures as the core metrics for better health at lower cost—the U.S. societal vital signs.

  • Life expectancy.

  • Well-being—measure of self-reported health status, as a general indicator of elements shaping quality of life.

  • Overweight and obesity.

  • Addictive behavior.

  • Unintended pregnancy.

  • Healthy communities—index of a community’s profile on health-related social and environmental dimensions, eg, education, housing, income, parks, and air and water quality.

  • Preventive services.

  • Care access.

  • Patient safety.

  • Evidence-based care.

  • Care match with patient goals—measure of the extent to which patient and family goals have been ascertained, discussed, and embedded in the care process.

  • Personal spending burden.

  • Population spending burden—measure of aggregate healthcare expenditures for a population relative to that population’s income.

  • Individual engagement—index of personal involvement in health-related behaviors, self-care, caregiving, and social activities that reflect a personal health orientation.

  • Community engagement.

Physicians’ bias and black lives

March 20, 2015by Robert Whitcomb in Uncategorized tagged , , , ,

 

In  an essay in The New England Journal of Medicine, David A. Ansell, M.D., and Edwin K. McDonald, M.D., discuss “Bias, Black Lives, and Academic Medicine.’

Among their conclusions:

“First, there is evidence that doctors hold stereotypes based on patients’ race that can influence their clinical decisions. Implicit bias refers to unconscious racial stereotypes that grow from our personal and cultural experiences….Although explicit race bias is rare among physicians, an unconscious preference for whites as compared with blacks is commonly revealed on tests of implicit bias.

“Second, despite physicians’ and medical centers’ best intentions of being equitable, black–white disparities persist in patient outcomes, medical education, and faculty recruitment. In the 2002 report Unequal Treatment, the Institute of Medicine (IOM) reviewed hundreds of studies of age, sex, and racial differences in medical diagnoses, treatments, and healthcare outcomes.The IOM’s conclusion was that for almost every disease studied, black Americans received less effective care than white Americans. ”

 

Obesity and chemicals

February 19, 2015by Robert Whitcomb in Uncategorized tagged ,

pollute

Physicians and others studying the social determinants of health would do well to follow this roundtable discussion on the links between obesity and exposure to toxic chemicals in the environment.  The Institute of Medicine says that “Speakers will make links between exposure to environmental chemicals and increased incidence of weight gain, glucose tolerance and insulin sensitivity, inflammation, and aspects of metabolic syndrome in animal models and human studies.”

Jenny Gold: Study: Suffering increases for dying Americans

February 4, 2015by Robert Whitcomb in Uncategorized tagged , , , , , , , ,

 

By JENNY GOLD 

jgold@kff.org | @JennyAGold

For Kaiser Health News
It’s been more than 15 years since the Institute of Medicine released its seminal 1997 report detailing the suffering many Americans experience at the end of life and offering sweeping recommendations on how to improve care.

So has dying in America gotten any less painful?

Despite efforts to build hospice and palliative care programs across the country, the answer seems to be a resounding no. The number of Americans experiencing pain in the last year of life actually increased by nearly 12 percent between 1998 and 2010, according to a study released Monday in the Annals of Internal Medicine. In addition, depression in the last year of life increased by more than 26 percent.

That’s the case even though guidelines and quality measures for end-of-life care were developed, the number of palliative care programs rose and hospice use doubled between 2000 and 2009.

“We’ve put a lot of work into this and it’s not yielding what we thought it should be yielding. So what do we do now?” asked study author Dr. Joanne Lynn, who directs the Center for Elder Care and Advanced Illness at the Altarum Institute.
The study looked at 7,204 patients who died while enrolled in the national Health and Retirement study, a survey of Americans over age 50. After each participant’s death, a family member was asked questions about the person’s end-of-life experience, including whether the person suffered pain, depression or periodic confusion. Those three symptoms were all found to have become more prevalent over the 10-year analysis.

One reason, Lynn said, is that doctors are using a greater range of high-tech treatments, which can lengthen the process of dying without curing the patient. “We throw more medical treatment at patients who are on their way to dying, which keeps them in a difficult situation for much, much longer,” she said. “We’ve increased the number of people put on ventilators and kept in hospitals, and we simply have more treatments that are possible to offer.”

The majority of our research, she added, focuses on wiping out diseases, rather than long-term supports or symptom management for people with chronic conditions or disabilities associated with aging: “Think about how much we invest in curing Alzheimer’s disease, and how little we put into making the course of Alzheimer’s better.”

Most physicians tend to under-treat pain and other symptoms at the end of life because they don’t recognize them or are hesitant to talk candidly about the process of dying and the pain associated with it, said Dr. Tim Ihrig, a palliative care physician at UnityPoint Health in Fort Dodge, Iowa.

“A lot of practitioners aren’t honest. We fail to empower patients with the truth,” said Ihrig. “In that setting, it’s easier to continue to do procedures and diagnostics rather than having that conversation, which is very honest and very difficult.”

Take a cancer patient who has stopped eating and is writhing in pain, he said. An oncologist might recognize the person is going to die, but rather than telling the patient, he or she begins another round of treatment that causes more pain and suffering.

“We don’t have the vernacular in our society to have the conversation about the end of life. People say, ‘I don’t want to take away someone’s hope.’ But in a metastatic pancreatic cancer, for example, we have to redefine what we mean by hope,” he said, citing one of the most deadly cancers.

Often, those conversations aren’t happening until the last days or hours of life, according to Ihrig.

Jonathan Keyserling, a senior vice president with the National Hospice and Palliative Care Organization, points out that half of all hospice patients receive hospice care for less than 30 days.

“If these patients had been under the care of a hospice or palliative care program [earlier], their pain and symptoms could have been brought under control for a much longer and sustained period of time,” Keyserling said via email.

It’s possible, however, that caregivers interviewed in the study simply reported more suffering, reflecting Americans’ changing awareness of pain and depression over the past decade.

“We’ve raised the expectation of better pain management over the years, which may make [the caregivers interviewed] more likely to report it,” says Rosemary Gibson, author of The Treatment Trap and senior adviser at The Hastings Center, a bioethics think tank based in New York. There are many more Americans diagnosed with depression today than in 1998, she added, “so it’s not surprising that people would report it more.”

Nonetheless, Gibson said, the country has a long way to go in improving care at the end of life. The increase in palliative care and hospice use over the last decade was just ”an oasis in the desert. We did nothing to stop the tsunami of overuse [of aggressive treatments] and doing things to people at the end of life that have no benefit.”

It’s time to pick up the speed of change, said study author Joann Lynn.

“We are all going to pass through this part of our lives, and we have a strong interest in its not being awful. So let’s buckle down and get it right.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.

 

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