Best Care Anywhere

by Phillip Longman

  Such precepts have long been recognized in the world of aviation, but no one had ever attempted to apply them systematically to the world of health care. Among Bagian’s key moves was to set up a system similar to those that exist within aviation whereby VA personnel could report mistakes and near misses anonymously. Given how often medical personnel not only fear blame but also feel shame when they make a mistake, the measure was essential to gathering enough data to see the patterns that were threatening safety.

  Many of these patterns involve highly technical procedures that are difficult to describe in lay terms, but others are straightforward and easy to understand. For example, most people have heard about surgeons who operate on the wrong organ or limb. It happened famously to comedian Dana Carvey, who nearly died in his forties after a surgeon unclogged the wrong artery in his heart. So-called wrong-site surgery happens in about one out of 15,000 operations, with foot and hand surgeons being particularly likely to make the mistake. Most hospitals try to deal with this risk by having someone use a magic marker to show the surgeon where to cut. But about a third of the time, Bagian’s safety team has found, the root problem isn’t that someone mixed up left with right; it’s that the surgeon is not operating on the right patient. How do you prevent that?

  Obviously, VistA helps a lot. One scan of the patient’s ID bracelet puts surgical orders up on the computer screen. But even VistA isn’t foolproof. What if someone mistyped the orders or made a mistake in coding the ID bracelet? Drawing on his previous NASA experience, Bagian developed a five-step process that VA surgical teams now use to verify both the identity of the patient and where they are supposed to operate. Although it’s similar to the check-off lists astronauts go through before blastoff, it is hardly rocket science. The most effective part of the drill, says Bagian, is simply asking patients, in language they can understand, to state (not confirm) who they are, their birth date or Social Security number, and what they are in for.

  Another safety measure taken by Bagian was equally simple and also an important lifesaver. Acting on tips from nurses, Bagian began noticing a significant number of instances in which patients were mistakenly injected with concentrated potassium chloride. This drug, which is normally used in diluted form to treat potassium deficiencies, is easily confused with sodium chloride (saline solution) or with liquid Tylenol, which comes in a similar bottle. The fail-safe solution: a policy of never allowing the concentrate to be stored in wards, backed up by bar coding of all medications.

  Following in the tradition of the Hardhats, this last measure, which is the single most important safety feature adopted by the VA, was made possible by ordinary VA employees acting on their own. While returning a rental car in 1992, a nurse in Topeka, Kansas, the late Sue Kinnick, saw for the first time the use of a bar code scanner. An agent used a wand to scan her car, scan her rental agreement, and then quickly sent her on her way. A light went on. “If they can do this with cars, we can do this with medicine,” Kinnick later told an interviewer.8

  With only minimal funding and management support, Kinnick joined with pharmacist Chris Tucker and fellow nurse Russ Carlson to develop the necessary software and run a pilot project in a thirty-bed gerontological psychiatry ward by 1994.9 Kizer says that when he got wind of this during a network managers meeting, he said, “Wow. That’s pretty impressive. I need to see this.” So he got on a plane and went out to Topeka, spent a day there, walked through with them how they did it, and said, “This is something we need.”

  Kizer had good reason to be enthusiastic. The software virtually eliminated dispensing errors. Just within the VA’s Eastern Kansas Health Care System, where it was first rolled out, it wound up preventing some 549,000 errors by 2001. There was a 75 percent decrease in errors involving the wrong medication, a 62 percent decrease in errors involving wrong dosage, a 93 percent reduction in the wrong patients receiving medicine, and a 70 percent decrease in the number of times nurses simply forgot or didn’t get around to giving patients their meds.10 At the time, there was no equivalent product available from the private sector, and even today, few hospitals outside the VA have automated their drug-dispensing systems.

  Meanwhile, after asking two outside consultants to evaluate VistA, Kizer had concluded that it, too, had no rival in the private sector and ordered its universal adoption. No longer would VA physicians be allowed to handwrite prescriptions and keep notes exclusively on paper; they’d have to learn how to use VistA if they didn’t already know. His decision wasn’t greeted with overwhelming acclaim. Kizer estimates that between 5 and 10 percent of VA doctors quit over the measure. But most, he says, were older specialists that the VA no longer needed because of its new emphasis on prevention and primary care. Moreover, the promise of VistA was just too great.

  Sue Kinnick’s drug-dispensing software, for example, could easily be folded into VistA, and together they became a powerful tool for safety. VistA’s electronic medical records take the guesswork out of whether a comatose or incoherent patient has a history of allergic reactions to penicillin or other drugs. Kinnick’s computerized dispensing system, meanwhile, takes the guesswork out of what some other doctor might have meant (Celexa, Celebrex, or Cerebyx; Sulfasalazine and Sulfadiazine?) with a cryptic scrawl or mumbled tape-recorded notes. In short, VistA became the “killer app” for the systematic prevention of medical errors and quality improvement.

  Bright Star

  Of course, medical errors still do occur in the veterans health-care system, and when they do, they are bound to make headlines. But when you see such a headline and wonder how safe veterans hospitals really are, the key question to ask is compared to what?

  Writing in the New England Journal of Medicine in 2005, Harvard’s Lucian L. Leape and Donald Berwick surveyed patient-safety efforts throughout American medicine and came to rather dreary conclusions. They noted that there was no statistical evidence that the rate of medical errors was declining for the American health-care system as a whole, and that there was plenty of reason to believe that new technologies and more powerful drugs were making being a patient still more dangerous.

  They despaired that there still did not exist any comprehensive nationwide monitoring system for patient safety and bemoaned the widespread denial among doctors that safety was a problem in medicine. “Why has it proved so difficult to implement the practices and policies needed to deliver safe patient care?” they plaintively asked. “Why are so many physicians still not actively involved in patient-safety efforts?” But amidst their gloom over lack of progress, they still saw hope in one shining exception.

  “The Veterans Health Administration quickly emerged as a bright star in the constellation of safety practice,” they wrote, citing its system-wide implementation of safety practices, training programs, and investment in safety research centers. They concluded optimistically that the rest of American health care would eventually catch up to the VA in its use of electronic medical records and wide diffusion of proven and safe practices.11

  But as we’ll see in the next chapter, this is not likely, barring very fundamental changes in the organization of American medicine. The veterans health system operates under unique incentives. It makes no money by providing unnecessary or ineffective treatments or tests. Instead, by promoting its patients’ long-term health and safety, it saves money while also gaining political support and thereby securing its future funding. Its doctors also form a self-selected population of professionals who tend to worry less about maximizing their own incomes and autonomy than about pursuing a calling. In short, the VA operates under conditions that give it a case for quality—a case that the rest of the American health-care system cannot make so long as it has little or no incentive to keep people well or make them better.

  SEVEN

  Who Cares about Quality?

  Medical economist J.D. Kleinke makes a revealing comparison between casinos and hospitals. Suppose you go to Las Vegas and after winning a few bets get hooked. When you start losing,
you find yourself going to the cage and converting all the money in your wallet into chips. Next you max out your credit cards. Later that night, with Lady Luck still flirting but denying you the big score, you convert your checking and savings accounts into still more chips. When these are gone twenty-four hours later, the casino happily lends you another $25,000 worth of chips, which represents 40 percent of your retirement account and 30 percent of the equity in your home. Then, sipping on yet another free scotch, you make one big last bet at the craps table and are suddenly struck by a massive heart attack.

  An ambulance rushes you to the nearest hospital. What’s different about your new location? For one, you’ve gone from an institution that knows lots about you and your past to one that knows practically, or maybe even literally, nothing. The casino, before it processed your credit cards or lent you money, used advanced but routine information technology to discover details about your life, such as your current employer, whether you’ve been caught at or suspected of cheating in another casino, your bank account balances, whether there are liens on your house, and whether your life insurance is paid up. All it needed to retrieve these details was your name, Social Security number, and a modest investment in information technology.

  But the hospital you arrive at clutching your chest has no ability to retrieve the information about your past that it needs to do its job—unless, of course, it happens to be a veterans hospital. Sure, a clerk can check out your insurance status by telephone, assuming you’re conscious or remembered to carry your insurance card. A clerk can maybe even find out if you’ve met your deductible, assuming the insurance company’s computers are “up.” But outside the VA, only a handful of hospitals has made the investment necessary to retrieve electronically, even from its own records, the name of your primary care physician, for example, or what medications you’re on, your history of allergic reactions to various drugs, or even the name of your next of kin. Nor can most health-care providers even communicate internally without relying on hand-delivered, handwritten notes, so that when an emergency room doctor scribbles out a prescription for beta-blockers, you wind up getting, well, who knows what?

  Casinos invest in information technology because it helps them with the business they’re in, which is encouraging impulsive gambling. Similarly, banks have found a business case for creating a highly integrated and sophisticated network of ATMs, to the point that you can draw cash from your account across the country and around the world. Yet hospitals make no equivalent investment in information technology to help them with the business they are presumably in, which most people would say is restoring people to health. Instead, American hospitals routinely endanger their customers and kill hundreds of thousands of them by clinging to nineteenth-century information technology. The question is why?

  Kleinke has an answer that is as rude as it is true. It has nothing to do with technological feasibility. As far back as the 1970s, as we’ve seen, amateur programmers working on VA word processors were banging out the code for the VA’s proven health-care information management system. Instead, Kleinke argues, the answer has to do with health care’s dirtiest of many dirty secrets: “Bad quality is good for business. And the surest road to bad quality is bad or no information.”1

  Quality Doesn’t Pay

  If this strikes you as too harsh, take a breath and consider. With the exception of the VA, what do most health-care providers get paid to do? Provide health? Hardly. They get paid to provide treatments, and there’s a big difference. This is not to suggest that most doctors are simply profit maximizers or indifferent to your health. Many in all walks of medicine are profoundly idealistic and believe in providing the highest-quality medicine possible. But given the system under which they operate, there is only so much idealism they can afford.

  That’s because, according to Lawrence P. Casalino, professor of public health at Weill Cornell Medical College, “The U.S. medical market as presently constituted simply does not provide a strong business case for quality.”2

  Casalino speaks from his own past experience as a solo practitioner and on the basis of over 800 interviews he has since conducted with health-care leaders and corporate health-care purchasers. While practicing medicine in Half Moon Bay, California, Casalino had an idealistic commitment to following emerging best practices in medicine. That meant spending lots of time educating patients about their diseases, arranging for careful monitoring and follow-up care, and trying to keep track of which prescriptions and procedures various specialists might be ordering.

  Yet Casalino quickly found out that his commitment to quality wasn’t sustainable, given the rules under which he was operating. Nobody paid him for the extra time he was spending with his patients. He might have eased his burden by hiring a nurse to assist with all the routine patient education and follow-up care that was keeping him at the office too late. Or he might have teamed up with other providers in the area and invested in computer technology that would have allowed them to offer the same coordination of care found in veterans hospitals and clinics today. Both steps would have improved patient safety and added to the quality of care he was providing. But even had he managed to pull them off, he stood virtually no chance of seeing any financial return on such investments. As a private-practice physician, he got paid for treating patients, not for keeping them well or helping them to recover faster.

  The same problem exists across all health-care markets, and it’s a major factor in explaining why the VA has a quality performance record that exceeds that of private-sector providers. For example, suppose a privately managed care plan follows the VA example and invests in a computer program to identify diabetics and keep track of whether they are getting appropriate follow-up care. The costs are all up front, but the benefits may require twenty years to materialize. And by then, unlike in the VHA system, the patient will likely have moved on to some new health-care plan. As the chief financial officer of one health-care provider told Casalino: “Why should I spend our money to save money for our competitors?”

  Or suppose an HMO takes a more idealistic attitude and decides to invest in improving the quality of its diabetic care anyway. Not only will it risk seeing the return on that investment go to a competitor, but it will also face another danger. What happens if word gets out that this HMO is the best place to go if you have diabetes? Then more and more costly diabetic patients will enroll there, requiring more premium increases, while its competitors enjoy a comparatively large supply of low-cost, healthy patients. That’s why, Casalino says, you never see a billboard with an HMO advertising how good it is at treating one disease or another. Instead, HMO advertisements generally show only healthy families.

  Indeed, any health-care provider in the private sector that holds itself out as providing high-quality care for chronic conditions risks financial ruin. That’s a lesson Beth Israel Medical Center in Manhattan learned after it opened a new diabetic center in March 1999. To publicize the new venture, Beth Israel convinced a former Miss America, Nicole Johnson Baker, herself a diabetic, to pose for promotional pictures wearing her insulin pump. She also posed next to a man dressed as a giant foot, a dark reminder of how poorly managed diabetes often leads to amputation.

  To avoid amputation and other dire outcomes, such as blindness and renal failure, the new center adopted a model of diabetic care that rivaled the VA’s in its quality. Highly coordinated teams taught patients how to check their blood sugar levels, count calories, and find the discipline to exercise, all while undergoing prolonged and careful monitoring. Within months, the center succeeded in getting the blood sugar levels of 60 percent of its patients under control—a stunning result that brought it national attention.

  But the idealists who conceived this program forgot the business they were in. Health insurers would pay only piddling amounts to cover the cost of a diabetic patient seeing a podiatrist, for example, though such care is essential to reducing the risk of amputation. And insurers would pay even less for nutrition c
ounseling, much less exercise classes. At the same time, as word of the center’s excellence in diabetic care spread, patient volume increased by 20 percent a month. Soon the center was running a large deficit, and Beth Israel administrators felt compelled to shut it down. Between 1999 and 2006, three similar centers in New York folded based on the same model of care, and for the same reason. Quality doesn’t pay.3

  It’s a similar story when it comes to the management of other major chronic conditions. For example, in 1995, Duke Medical Center had the bright idea of offering an integrated, supportive program for patients with congestive heart failure. Nurses regularly called patients at home to monitor their well-being and to make sure they took their medications. Nutritionists offered heart-friendly diets. Doctors shared data about their patients and developed evidence for what treatments and dosages had the best results. And it worked—at least in the sense that patients became healthier. The number of hospital admissions declined, and patients spent less time in the hospital. The only problem? By 2000, the hospital was taking a 37 percent hit in its revenue due to the decline in admissions and the absence of complications.4 Ten hospitals in Utah had a similar experience after implementing integrated care for pneumonia.5

  Another example is Intermountain Healthcare, a network of hospitals and clinics in Utah and Idaho that many experts have described as a model for health reform. Intermountain is inspiring. Founded by the Church of Latter Day Saints, though now operating independently, it maintains a highly idealistic culture that is focused on measurement and a commitment to evidence-based medicine. Its CEO once explained to me that because of its large market share and comparative lack of churning in its patient base Intermountain has the same incentives the VA does to invest in effective disease management. This is no doubt true to a degree, but Intermountain still winds up being punished for doing the right thing. For example, when it developed a better protocol for taking care of premature babies, it managed to reduce the use of ventilators by more than 75 percent. Yet this triumph cost Intermountain $329,000 in foregone revenue it had previously been making off inferior care.6