It’s frustrating that hospitals and administrators have become increasingly involved in the delivery of medical care by physicians in an attempt to manipulate the institution’s public statistics. It’s also frustrating that this approach is being driven by the ‘so-called’ groups that advocate quality. Where groups such as the JCAHO, Institute of Medicine and the States that publish ‘Quality Measures’ purport to aim to improve quality, all they do is cause the degradation of quality medicine by forcing physicians and hospitals to focus on ensuring the ‘data looks good’. Published Data about hitting targets for treatment of certain medical conditions (DVT prophylaxis rates, Health Care Associated Infection Rates, Influenza Vaccination rates, etc) do nothing to indicate whether a Physician is a good one, whether they can actually make a diagnosis and treat a patient at a high level. Now, individuals who make sure that the ‘data’ looks good will be considered the ‘good ones’ even if they couldn’t take care of my dog.
Hospitals have become expert at manipulating Ventilator Pneumonia rates, Line infection rates, Mortality, etc. Did you know that in many hospitals in NY, NJ and PA there have been ZERO Ventilator Associated Pneumonias in the last 5 years…..and despite this there have been quite a few!!!!
The quality measure that tracks the ‘Time from Admission Decision’ in the ER to transfer out of the ER has led to patients being diagnosed and admitted with ‘bridging orders’ even though the diagnosis isn’t close and the bridging orders merely say ‘admit to floor’ with no diagnostic or treatment orders…..but, although the patient will languish on the medical floor awaiting real orders and a real diagnosis….the quality is excellent because the patient made it out of the ER in less than 90 minutes. Gotta love the priorities!!!!!
Then there is the push for the almighty Electronic Medical Record (EMR) and Computerized Physician Order Entry (CPOE), which are also supposed to improve quality. How, I’m not so sure, but it’s supposed to. Now we have Emergency Physicians sitting at computers typing instead of at the bedside diagnosing and treating. Next up…..the same in the ICU’s…..which will lead to very cursory discussions of patient issues and treatment plans because it takes forever to type it all out. Now what you’ll see is just a list of problems without any discussion of the issues and plans. So much for quality through improved communication and discussion.
I recently received a note from the Electronic Record of a Cardiologist at the University of Pennsylvania, a quality institution. The note included list of Assessment diagnoses and a list of Plans, all generated by clicking off the correct boxes, and not a thing was discussed about what the clinician thought and why…..I have no idea what he thought. I already knew the list of diagnoses but wanted to know what his thoughts…..and nothing!!!! So much for the record being a place to discuss your thoughts and plans in a detailed fashion. I will say, it was a perfect note….had all the components and Systems Review to receive the highest level of coding and billing!!!!
As for order entry….in an attempt to create uniformity, it has become impossible to individualize treatment on a daily or minute to minute basis, unless you want to jump through major hoops to do so. And when you have 30 patients to see, who is going to sit and spent 20 minutes typing orders when the hand written version would have taken 3 minutes……and would have been more to the point and detailed what you actually wanted to have happen. Ahhhhh….cook book medicine (or should I say ‘evidence based medicine’). I do understand the intent….now you don’t have to be smart and well trained, or experienced and talented, to practice medicine….all you have to do is click the right boxes and we’ll all look the same!!!!
Now, I’m all for Evidence Based Medicine, in fact I’ve been practicing that way since before it became in vogue, it’s just how I was trained at the U of P…but….no two patients are the same. And therefore, no two treatment plans should be same, not even close!!!! Too bad, but now you merely have to click the ‘Pneumonia order set’!!!!!
Well, that’s my rant for today!!!