Monday, December 15, 2008

A Story About Quality of Care

Recently, Tom Daschle invited Americans to discuss health concerns. In the healthcare standards space, you'll find that most of us have a large number of stories to tell. Most of our personal stories in healthcare are about something that could have been done better. They feed our passion for better healthcare, and help us to formulate opinions on what is of strategic importance.

A new story entered my repetoire recently. My step-father died last night, after a long struggle to recover from open-heart surgery over six weeks ago. This was his second open heart surgery in two years. I'm still somewhere between Shock and Denial and the Pain and Guilt stage of grieving. As I go through these stages, questions go through my head on what we could have done differently to ensure he survived.

Two questions gnaw at me:

Was he getting the best care in the area that he could have? I cannot answer that question as well as I would like to be able to. Even so, my mother and I probably have better answers than most patients or their families would. I have a rather elaborate network of physician contacts located in that area and elsewhere. The gave me good anecdotal feedback on the quality of physician care provided by the hospital where his surgery was performed. My step-father has had heart problems for quite some time, and my mother was rather engaged to make sure he had high quality care. Even so, I feel like the amount of information we all had was really insufficient. What would have been most helpful to us would have been a simple listing by procedure of the success rate and number of patients treated at area institutions, classified by the risk category of the patient. My step-father would have fallen into the high-risk category.

Was his cardiologist was the best provider of care for him, or would another have been better? His most recent cardiologist determined that he had yet another valve failure, something his previous provider hadn't found. The newer provider could possible have found that problem in the workup for the open heart surgery he had two years ago. Might that have resulted in his survival?

How would I have objectively compared his two cardiologists? I would like to have seen how a similar case mix of patients faired for each provider. I don't know exactly how to measure success or failure, but others do. I would also be interested in comparing the costs for those results.

A logical outcome of how our health system works is that information about quality of care needs to flow through the entire system. When I'm purchasing health coverage, I really want to know whether my payer is providing the best possible healthcare for me and my family. We need to extend the measure of quality of care not just to the providers of care, but also to those organizations that manage and negotiate the costs and quality of the care that we can obtain. Payers seem to be willing to pay for performance. They should also be willing to report on their own.

As for myself, I think I will measure results by the stories I hear. Tell me yours.

Tuesday, December 9, 2008

Book Review

Not too long ago, I ordered a copy of "Critical: What we can do about the Health-Care Crisis", by Senator Tom Daschle (President-Elect Obama's choice for Secretary of HHS) with Scott Greenberger and Jeanne Lambrew. The book was sold out in my local bookstores, so I ordered it online. It arrived yesterday, and I've just finished reading it today.

The book itself is fairly short, about 200 pages. Organized into five parts, the book first introduces the crisis in healthcare, talks about what's been done to reform healthcare in the last century, and describes why these efforts failed. Next it describes the Sentator's ideas for solving the problem. He closes by calling for change in the healthcare system that sticks. I found the first three parts of the book to be of little interest personally. However, I understand why they are included in the book.

The key focus of the book is the notion of a Federal Health Board, and independent body modeled after the Federal Reserve. The members of the board would be experts in healthcare appointed by the President, and approved by Congress. The board would set policy on how private insurers participate in Federal health programs. It would recommend coverage of proven drugs, procedures and therapies for the treatment of specific diseases. What makes the idea of the FHB march is the expansion of the Federal employee health benefits and Medicare programs to include plans that would allow members of the public to participate. It might also unify federal coverage so that members of the military, the Federal government, and those obtaining care under Medicare obtain similar benefits for similar costs.

Other key objectives of the FHB made in the book include:
  • Focusing on prevention
  • Ensuring universal coverage
  • Equity not just for general healthcare, but also dental and mental health coverage
In addition to these goals, the FHB would also continue existing programs to increase transparency into healthcare costs, improve and measure quality of care, and change the focus from payment for services to payment for performance.
Daschle speaks somewhat about the use of electronic health records in the book, but devotes only a handful of pages to the topic. He notes that the US is woefully behind the rest of the world in use of healthcare information technology, and that we could save as much as five percent of our total healthcare spending (some $1.66 trillion in 2003) by implementation of a fully electronic healthcare system. He suggests tax breaks, loans or loan-guarantees to health-care institutions to enable them to upgrade their health IT systems.
This isn't a great book, but it does have some interesting insights. If you will be dealing with healthcare policy issues in the US, I'd recommend reading it.

Wednesday, December 3, 2008

The Right Tools

The right tools make any job easy. I've just had that proved to me again. Recently I was called upon to XDS-I enable a prototype that already worked with XDS. Now, you have to realize that while I know quite a bit about XDS, until about four weeks ago, I could honestly say I knew nothing about DICOM and get away with it. When I implemented XDS 4-5 years ago, it took me about 4-6 weeks of effort. When I implemented ATNA (TLS and Audit Trails), it took me about 2 weeks. I expected this DICOM project to take me 2-3 weeks of effort. Boy was I surprised with the real effort.

I spent about two days reading the DICOM specification, spent an hour talking to a DICOM expert (which if I had done sooner would have cut my DICOM reading in half), and a half day reading the XDS-I specification. Then I hit the web searching for DICOM toolkits written in Java. I found several, and after some detailed review, I picked a fairly reputable one to work with.

After adding 15 lines of Java code and modifying about 50 lines of a 600 line XSLT stylesheet, I had XDS-I enabled the application (it already understood XDS). The code and stylesheet modifications took about 2 hours to write.

An IHE profile in half a week; that's worth bragging about. But, I can go one better: Last Saturday night I used the implemention of the XDS-I that I had developed and the same toolkit to implement the PDI profile. It took me about six hours. Once again, the key was having the right tools.

Most of what I work with is open source, or freely available tools. I love Java, Tomcat, Xerces and Xalan. I use Eclipse as my Java IDE. One of the benefits of clearly written standards and integration profiles is that others are implementing them for me. That allows me to focus time and effort on improving other things. I don't need to do what others have done just to show I can do it better. I'd rather save my time and effort to work on things that others haven't done before.

I can no longer say that I know nothing about DICOM, but I can still honestly say that I didn't write one lick of code dealing with it. So, this year, I've been playing the role of a patient at RSNA IHE demonstration, and maybe next year I can play Radiologist.