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  • #16
    Michael- I really don't care about the data, and I was only guessing as to why they were giving the discount, I just know that I PAY LESS!

    Comment


    • #17
      the true meaning of the force

      Oh now ma$ter I under stand the real force.
      let the dollar$ be with you

      Comment


      • #18
        Originally posted by hirschr
        Michael- I really don't care about the data, and I was only guessing as to why they were giving the discount, I just know that I PAY LESS!
        I have talked to the Illinois company about this very topic, when I was researching the possibility of giving a discount, and learned that they are doing it for marketing reasons. Interestingly enough, in this very, very tight insurance market, most of the marketing-type discounts are going away.

        Regards,

        Michael Lloyd

        Comment


        • #19
          Originally posted by Kursk
          7% admissions with med errors, 66% not caught, 25% of those result in adverse event
          Is this really true?

          Comment


          • #20
            "Incidence rates of ADEs vary from 2 per 100 admissions to 7 per 100 admissions among the hospitals that have conducted ADE studies (1,5,10,11). A precise national incidence rate is difficult to calculate because various researchers use different criteria to detect and identify ADEs (12).

            ADEs can result in a number of different physical consequences, ranging from allergic reactions to death (1,4,5,9,10,12,13). One study estimated that 9.7 percent of ADEs caused permanent disability (14). Another study estimated that the increased risk of death for a patient who experiences an ADE is nearly twice that of a patient who does not (1). Figure 1 (Text Version) illustrates the distribution of several types of injuries among patients who suffered ADEs"

            http://www.ahrq.gov/qual/aderia/aderia.htm

            Why aren't doctors at the forefront screaming for Computerized Physician Order Entry (CPOE) to protect patients? Wouldn't that help us regain our tarnished image?

            Comment


            • #21
              K, I wonder why all the attention is on EMR when simply introducing CPOE in all hospitals would go along way in cutting down errors, I am with you on this one. I trained at a place with a Unix based one, I forget the name, took only a few minutes to learn as a resident, it would catch interactions, patients that are NPO being prescribed PO meds, had prompts for therapeutic drug monitoring and IV->PO conversion.
              M
              Mel
              There is no place like 127.0.0.1

              Comment


              • #22
                Mel unfortunately to get the most out of clinical decision support (suggestions at the time of prescribing) CPOE has to be linked to most of the data sources containing patient infor including ADT, pharm, lab, drug reference for CDS and for order output it needs to be linked to every system that can receive an order (PT/OT/RT/rads/pharm/lab/ADT etc). Fully functional (complete electronic transition) CPOE is therefore the capstone on a pyramid of functionality that has to be in place and communicating to provide the necessary data for CDS. Hence EMR then CPOE. There are examples of computer order entry without the other systems but it usually offers less CDS and is a parallel system existing next to a paper system or used only by proxy (nurse/ward clerk).

                Comment


                • #23
                  Originally posted by Kursk
                  Mel unfortunately to get the most out of clinical decision support (suggestions at the time of prescribing) CPOE has to be linked to most of the data sources containing patient infor including ADT, pharm, lab, drug reference for CDS and for order output it needs to be linked to every system that can receive an order (PT/OT/RT/rads/pharm/lab/ADT etc).
                  The system we used as a resident did all this, I think what scares most computer phobics is "taking away their charts" and dictation. Having all the orders entered on the CPOE eliminites a lot of the opportunity for error if the physicians enter the orders personally. I cannot recall the software, but have seen it in other hospitals where it was not being used to it's full potential, because nurses and unit clerks entered the orders instead of the prescribers, creating another opportunity for errors.
                  Mel
                  Mel
                  There is no place like 127.0.0.1

                  Comment


                  • #24
                    Calling Michael Lloyd

                    I'd love to hear from you on the state of tort reform. Lots of democrats stating that malpractice is only 1/2 a percent of health care costs and lots of republicans saying it's key to reducing costs (while at the same time using doctors as cause to attack corporate liability as well).

                    Comment


                    • #25
                      I hope Lloyd will get back to you. The cost is partly what you include in it. Is the cost just the payout, or is it that plus the legal fees of both sides, the insurance paid by hospitals , institutions, and doctors to cover "malpractice" and/ or the cost of extra tests and procedures to reduce "liability". It is not an easy number to figure unless you just count the court mandated penalties.

                      Comment


                      • #26
                        As with so many things statistical, you can torture the numbers to support almost any side of the issue. Tort reform is no different. Not even the experts can agree on a common methodology used to select the numbers to calculate the total financial cost of medical liability. I think the numbers and reports prepared by the General Accounting Office and some other Federal government agencies on this topic are probably the most accurate and least prone to bias.

                        But the numbers are largely irrelevant. We should be asking ourselves the more global question: what do we want our medical liability system to accomplish? Is it to fairly compensate the injured? Is it to deter bad practice? Is it to punish wrong-doers? This is what we should be asking ourselves as a society.

                        Speaking from the viewpoint of working in the malpractice area for twenty years, and having worked up several hundred cases, our current system does an absolutely terrible job of accomplishing any of the three goals listed above. Given the lottery aspect of the liability system, people with deserving claims sometimes get nothing, while people with questionable claims hit the jackpot. Since around 70-80% of all malpractice trials find in favor of the physician, can we really say that fear of liability deters bad practice? Malpractice liability can be a check and balance, but I don't believe it acts as a widespread deterrent. And does a malpractice claim punish a wrong-doer? Not really. The insurance company pays the money, not the individual physician. Malpractice cases sometime come to the attention of the state licensing board, and they can take action, but most licensing sanctions are triggered by patient or staff complaints, not malpractice cases.

                        If I could wave my magic wand and come up with a solution, we would have a no-fault compensation system for adverse outcomes, very much like workers' compensation. Cases would be heard by expert panels or judges, instead of a jury. Future medical expenses related to the injury would be covered. Pain and suffering damages woudl be limited, with the emphasis placed on medical rehabilitation and recovery. Cases of questionable practice or conduct would be referred to the state licensing board for investigation and action. We would pay for this system by a combination of Federal government funding and physicians fees, to replace malpractice insurance premiums.

                        I do not expect to see this in my lifetime.

                        Regards,

                        Michael Lloyd

                        Comment


                        • #27
                          Thanks ML, good points all around. I remain very pessimistic about this as those running for office all seem to be reading a prepared position statement that demonstrates very little understanding of health care, malpractice and consumer demands/finances. We seem to lack the will to learn about this and the political ability to make hard choices and craft a workable solution. I don't really see anything changing with the election.

                          Comment


                          • #28
                            Thanks ML

                            Greatly enjoyed your thoughts and observations, many thanks for taking the time to share. Clearly you know more about this that I ever will, perhaps you can provide some feedback on the following guess. In order to calculate an appropriate discount for a given intervention, there would have to be a fairly good body of information on the relative risks of each. With no EHR standards and no standarized implementation or use measures, it would be hard to calculate an appropriate incentive to implement an EHR. Is that part of the problem?

                            My own observation is that it will be a long time before there is a sufficient amount of information to do risk calculations. Lawyers are still thrilled to have legible records and ask no questions about how "real" the information in them is. There has been some case law established involving EHRs (I will provide a link if there is interest). However, there is still a presumption that a reasonable criterion for the legitimacy of an EHR record as a true medical record is grounded in the concept that the system was "functioning as designed" during that time in question. A tongue-in-cheek observation might be that some EHRs were designed to facilitate improper documentation, so if the system creates a record that does not qualify as a medical record by design...

                            If I was an insurance company I would consider designing an incentive program in the context of setting up a risk assessment study. Perhaps the company would offer a discount to some fixed number of clients with some limited variability among them, with the proviso that the insurance company be allowed to collect data from time to time on the actual use of the system. Over time, the company would build a database on what raises and what lowers risk. Perhaps there is an insurance industry group that could undertake this on behalf of all insurers, at least to prove the concept?

                            The only one I have learned a little about is the Colorado Physician Insurance Company or COPIC. COPIC has apparently gone to some effort to quantify risk management and mitigation relating to EHR implementations. One of their resources, a consultant named Barbara Drury, gave a very interesting presentation on risk assessment and mitigation in EHR implementations at HIMSS 05. It was largely qualitative but it did seem to present a reasonable framework for evaluating risk relating to quantifiable variations in EHR designs, implementations, and use. My own organization's work in developing standardized testing protocols for documentation functions will, I hope, provide a model for reproducible testing of EHRs against basic medical records principles and so thereby help control the variability among the products themselves when comparing and contrasting for selection or other purposes.

                            In any case, until there is more demand that vendors produce and support EHRs that take into account the fundamental standards of medical records as computer-based business records, can there be any basis for meaningful comparison of EHR-related risk? As it is now, since so few pay any attention to the business rules in an EHR, they may unknowingly be using a poorly or improperly designed system that doesn't necessarily help or hinder risk. In this environment it seems likely to me that a practice that has poor documentation practices will still be at higher risk whether using an EHR or paper. Conscientious people will be conscientious whether they have an EHR or not.

                            My own concern is that some EHRs will actually increase risk for conscientious providers because the system will not allow one to discriminate between someone doing things right and someone doing things wrong. One example is the many EHRs with audit functions that only show who altered the record and when. There is no way to reproduce the "before" and "after" so that a simple repair of a spelling error cannot be distinguished from a major alteration. In such a case a savvy attorney will be able to cast doubt on the documentation of even the most careful doctor, because the system will make truly innocent actions indistinguishable from corrupt acts.

                            Most worrisome was a recent statement by the chair of the functionality workgroup of CCHIT who, when asked about risk impacts of EHRs stated that she was unaware of any information to suggest an EHR can have an impact on risk...

                            I look forward to your response ML.

                            RDGelzer
                            Wallingford, CT
                            r.gelzer@snet.net

                            Comment


                            • #29
                              One part of this has been extensively investigated

                              Originally posted by Michael Lloyd View Post
                              As with so many things statistical, you can torture the numbers to support almost any side of the issue. Tort reform is no different. Not even the experts can agree on a common methodology used to select the numbers to calculate the total financial cost of medical liability. I think the numbers and reports prepared by the General Accounting Office and some other Federal government agencies on this topic are probably the most accurate and least prone to bias.

                              But the numbers are largely irrelevant. We should be asking ourselves the more global question: what do we want our medical liability system to accomplish? Is it to fairly compensate the injured? Is it to deter bad practice? Is it to punish wrong-doers? This is what we should be asking ourselves as a society.

                              Speaking from the viewpoint of working in the malpractice area for twenty years, and having worked up several hundred cases, our current system does an absolutely terrible job of accomplishing any of the three goals listed above. Given the lottery aspect of the liability system, people with deserving claims sometimes get nothing, while people with questionable claims hit the jackpot. Since around 70-80% of all malpractice trials find in favor of the physician, can we really say that fear of liability deters bad practice? Malpractice liability can be a check and balance, but I don't believe it acts as a widespread deterrent. And does a malpractice claim punish a wrong-doer? Not really. The insurance company pays the money, not the individual physician. Malpractice cases sometime come to the attention of the state licensing board, and they can take action, but most licensing sanctions are triggered by patient or staff complaints, not malpractice cases.

                              If I could wave my magic wand and come up with a solution, we would have a no-fault compensation system for adverse outcomes, very much like workers' compensation. Cases would be heard by expert panels or judges, instead of a jury. Future medical expenses related to the injury would be covered. Pain and suffering damages woudl be limited, with the emphasis placed on medical rehabilitation and recovery. Cases of questionable practice or conduct would be referred to the state licensing board for investigation and action. We would pay for this system by a combination of Federal government funding and physicians fees, to replace malpractice insurance premiums.

                              I do not expect to see this in my lifetime.

                              Regards,

                              Michael Lloyd

                              On the last suggestion involving the wand, I'd like to point out that a study was done in volving this solution. It was done in New York City. A panel of doctors found that of all the "malpractice" like events, only ten percent ever came to suit. It is just plain a lot of hassle to bring a lawsuit. It is never free. Ninety percent just move on, for whatever reason.

                              I had a friend who was an MD JD who was a consulting thoracic surgeon on this panel, and so I found out from him exactly the methodology they used, and it was thorough and exacting.

                              So it is theorized that if all you had to do to receive compensation was fill out a form, then the amount of payouts would possibly increase ten fold. You could argue it would increase it five fold, but you could never argue that it would be revenue neutral.

                              So once that study's results were published in the New England Journal of Medicine, everyone immediately stopped talking about a worker's comp type system for med mal.

                              Now I'm sure not saying I have any type of solution. I'm just saying if you wish for something, you may get it, and where that would lead you?

                              I can tell you for a fact that Indiana's rates are lowest, because they have a medical tribunal panel methodology, which is essentially an "informed" judge approach. They use a panel of three doctors who are from different counties from the doctor being sued. The panel, of course, must affirm that they do not know the doctor involved. Indiana has the lowest med mal rates in the country.

                              The system was instituted by Otis Bowen, MD in the 70s when he was governor, I'm not 100% sure on the dates.

                              I agree this is a raging debate, and must go on, how to modify the effect of medical malpractice litigation on our system of health care. It is crippling in many states. Crippling to doctors. And the practice of defensive medicine is very real, and affects the decision making of a doctor.

                              I might also address your assertion that malpractice, "The insurance company pays the money, not the individual physician." The individual doctor pays a heavy price in being enshrined in the data bank. It has a severely limiting effect on the latitude of one's career. The doctor ends up explaining that situation the rest of his/her life, or he/she stops moving. And in some states malpractice insurers can leave the state, and they have, and doctors can not find replacement insurance.

                              And usually it is the rare case that goes to trial that does not forever affect a doctor. I was involved with one where an orthopedic surgeon had a heart attack right in the middle of the trial. He was hospitalized and the trial continued. The jury did not witness the heart attack, so the trial continued, and they were advised by the judge to take nothing from the fact that the doctor was not there. It is an assault at the very heart of the doctoring process, and that is decision making in the face of uncertainty that doctors were willing to live with in the service of other human beings. It plain hurts to be sued.

                              Comment


                              • #30
                                Originally posted by Anon_182a1a View Post
                                And usually it is the rare case that goes to trial that does not forever affect a doctor. I was involved with one where an orthopedic surgeon had a heart attack right in the middle of the trial. He was hospitalized and the trial continued. The jury did not witness the heart attack, so the trial continued, and they were advised by the judge to take nothing from the fact that the doctor was not there. It is an assault at the very heart of the doctoring process, and that is decision making in the face of uncertainty that doctors were willing to live with in the service of other human beings. It plain hurts to be sued.

                                A urologist in Florida committed suicide after he was found liable for complications after an attempted vasectomy reversal. The plaintiff's attorney blamed the doc's insurance company for not settling.
                                HOT

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