The New York Times just published a heartbreaking exposé about medical tubing and deaths that can result from nurses and doctors inserting the incorrect tubes into patients’ veins and bodies – ie inserting a feeding tube into a vein. http://www.nytimes.com/2010/08/21/health/policy/21tubes.html?_r=1&ref=health
Patients, hospitals, and many in the industry advocate making different kinds of tubing for different functions that are incompatible with one another so that this kind of mistake could not be made. However, this initiative has run into major regulatory hurdles as the FDA has been slow to insist that this kind of tubing be put into use and industry advocates have challenged the necessity.
The article is disheartening for a number of reasons. The FDA is largely considered the most successful US regulatory agency (http://www.newyorker.com/talk/financial/2010/06/14/100614ta_talk_surowiecki ), yet even it has major systematic process errors like the ones described in the article that allow it to approve devices closely resembling those that have been recalled. It also, like many government agencies, is not a fast-moving body. The tube issue is clearly one it clearly must correct, yet the response has been incredibly slow. The article also brings to light the flaws of a system that gives too much voice to industry concerns. This is a case in which a simple adjustment of design would prevent a simple mistake from killing a patient; clearly, it’s a time when the public interest needs to outweigh the demands of a business. However, industry lobbying has slowed the process and allowed for more deaths to occur.
However, in some ways be seen as inspiring. The issues with tubing can be easily solved once hurdles are cleared. There are many cases in medicine where simple changes can begin to eliminate unnecessary loss of life. Coordinating such changes will be a massive challenge, but such changes are possible. Standardizing medical devices so that doctors will not waste time figuring out how to use a new machine, setting up operating trays in the same way, implementing electronic record-keeping, and many other examples will help prevent mistakes from being made when they are eventually implemented. There are so many clear paths forward in improving medical care and preventing medical errors; the challenge will be in sticking with these plans and following through on implementation. Key to this will be reforming the medical device industry -- forcing companies to standardize designs and adhere to safety-maximizing standards will be a huge, but not insurmountable challenge.
Sunday, August 22, 2010
The difficulty of digital medical record keeping
Throughout the debate about so-called Obamacare, one topic that particularlyinterested me was the push to digitize medical records. Digitizing records makes so much sense and is almost universal practice in profit-oriented American companies – how has it taken this long to apply the practice to medicine? Digitizing records should be even more important in medicine than in many other industries – my allergist in NY needs to know what my allergist in Michigan and my general practitioner know or else they might not have all the relevant facts to treat me. Paper record sharing is far too burdensome to allow this, among many other things, to happen.
I was interested in this article: http://blogs.wsj.com/health/2010/08/18/study-only-advanced-electronic-medical-records-reduce-er-time/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+wsj%2Fhealth%2Ffeed+(WSJ.com%3A+Health+Blog)&safe=on&mod=smallbusiness about a study that showed that although ERs with advanced digital record-keeping systems have about 20% lower wait times than those with little or no digital record keeping, those with mixed systems have wait times 47% longer than those with no electronic record keeping for those with urgent or semi-urgent issues. The kicker: only 1.7% of the ERs in the study had fully functional digital record keeping.
This is a situation where the upfront cost is high, but the long-term payoff is huge and really essential to the future of health care. Independent studies have shown the Obama plan to create a standardized computer record-keeping system for the nation would cost a whopping $75-100bn to implement; however, some estimates show that once in place, it could save between $200-300bn/year – see http://money.cnn.com/2009/01/12/technology/stimulus_health_care/.
I think the key implication of the first study is that these record-keeping systems have to be designed extremely carefully in order to have the full impact possible. While the advantages of the switch go well beyond decreasing wait times at ERs, there are many ways a system could be created that would cause more harm than good. It’s something that we absolutely have to get right the first time – an intuitive, practical, and standardized system of medical record-keeping would be a powerful tool in reducing costs and improving care in the medical system. Creating this – see the above article for details – will require clearing some rather high hurdles, but I think it’s a very worthwhile point of focus in the process of health care reform.
I was interested in this article: http://blogs.wsj.com/health/2010/08/18/study-only-advanced-electronic-medical-records-reduce-er-time/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+wsj%2Fhealth%2Ffeed+(WSJ.com%3A+Health+Blog)&safe=on&mod=smallbusiness about a study that showed that although ERs with advanced digital record-keeping systems have about 20% lower wait times than those with little or no digital record keeping, those with mixed systems have wait times 47% longer than those with no electronic record keeping for those with urgent or semi-urgent issues. The kicker: only 1.7% of the ERs in the study had fully functional digital record keeping.
This is a situation where the upfront cost is high, but the long-term payoff is huge and really essential to the future of health care. Independent studies have shown the Obama plan to create a standardized computer record-keeping system for the nation would cost a whopping $75-100bn to implement; however, some estimates show that once in place, it could save between $200-300bn/year – see http://money.cnn.com/2009/01/12/technology/stimulus_health_care/.
I think the key implication of the first study is that these record-keeping systems have to be designed extremely carefully in order to have the full impact possible. While the advantages of the switch go well beyond decreasing wait times at ERs, there are many ways a system could be created that would cause more harm than good. It’s something that we absolutely have to get right the first time – an intuitive, practical, and standardized system of medical record-keeping would be a powerful tool in reducing costs and improving care in the medical system. Creating this – see the above article for details – will require clearing some rather high hurdles, but I think it’s a very worthwhile point of focus in the process of health care reform.
Revisiting swine flu (yes, the namesake of this blog)
I hadn’t really thought about swine flu since I (along with 40% of my classmates according to unofficial University Health Services estimates) was stricken with it during Harvard commencement last year. I remember hearing that the strain of the virus wasn’t nearly as bad as had been feared and most people ended up like my roommates and I – coughing, sleeping and drinking orange juice for a few days before making a full recovery.
Two things brought it back to my attention recently:
1) I’m reading The Great Influenza, an excellent book by John Barry published in 2004 about the 1918 so-called “Spanish Influenza.” It turns out that the strain of the flu in 1918 was also H1N1. So what does that mean? Influenza viruses are defined by their protuberances: hemagglutinin (the part of the virus that binds to the cell the virus takes over) and neuraminidase (the part that allows the virus to distribute from the cell once it has taken over) – H and N. The type of hemagglutinin and the type of neuraminidase are classified by numbers; both of these shift and change to make H3N2 (Hong Kong Flu), H5N1 (bird flu) and the many different types of flus that require a different shot every year. However, even though last year’s swine flu was in the same category as the 1918 flu, it was obviously a very different strain. Even within the 1918 flu itself, there was an original, much milder form of the virus that preceded the devastating one that killed between 50 and 100 million people. My point? Flu is a crazy, crazy virus, and I think I finally understand the paranoia of last year – as happened in 1918, the virus could very easily have shifted to something more deadly that retained the highly contagious qualities of our commencement swine flu. Another point: I highly recommend The Great Influenza – especially pgs 98-106 in which Barry explains the mechanism of infection and change of the flu virus.
2) This article in The Wall Street Journal last week: http://online.wsj.com/article/SB10001424052748703435104575421591518817872.html The WHO just declared the Swine Flu Pandemic over – I thought it had been over for a long time! Apparently the mere classification of last year’s incidence of H1N1 as a pandemic has been a major point of contention – WHO officials admitted that it would be helpful to have different vocabulary to describe the types of disease so that a relatively manageable issue like last year’s H1N1 would not fall into the same category of pandemic as a disease like HIV/AIDS. Given that H1N1 killed only 18,449 people last year, it is difficult to believe it needs to be given such a special classification when a normal seasonal influenza would often kill more than that and countless diseases around the world are comparable killers. Each of the top 10 most deadly infectious diseases kills >50,000 people annually. I believe the extra attention swine flu got was due in part to its concentration in the developed world and in part due to the fear that the disease would become a more deadly strain.
Both The Great Influenza and the case of last year’s swine flu are making me realize one of the great challenges of public health – striking a balance between ensuring all precautions are taken and keeping public fear to a minimum. In the 1918 flu, officials fell firmly on the side of doing too little, too late, while last year, officials quite possibly did too much.
Two things brought it back to my attention recently:
1) I’m reading The Great Influenza, an excellent book by John Barry published in 2004 about the 1918 so-called “Spanish Influenza.” It turns out that the strain of the flu in 1918 was also H1N1. So what does that mean? Influenza viruses are defined by their protuberances: hemagglutinin (the part of the virus that binds to the cell the virus takes over) and neuraminidase (the part that allows the virus to distribute from the cell once it has taken over) – H and N. The type of hemagglutinin and the type of neuraminidase are classified by numbers; both of these shift and change to make H3N2 (Hong Kong Flu), H5N1 (bird flu) and the many different types of flus that require a different shot every year. However, even though last year’s swine flu was in the same category as the 1918 flu, it was obviously a very different strain. Even within the 1918 flu itself, there was an original, much milder form of the virus that preceded the devastating one that killed between 50 and 100 million people. My point? Flu is a crazy, crazy virus, and I think I finally understand the paranoia of last year – as happened in 1918, the virus could very easily have shifted to something more deadly that retained the highly contagious qualities of our commencement swine flu. Another point: I highly recommend The Great Influenza – especially pgs 98-106 in which Barry explains the mechanism of infection and change of the flu virus.
2) This article in The Wall Street Journal last week: http://online.wsj.com/article/SB10001424052748703435104575421591518817872.html The WHO just declared the Swine Flu Pandemic over – I thought it had been over for a long time! Apparently the mere classification of last year’s incidence of H1N1 as a pandemic has been a major point of contention – WHO officials admitted that it would be helpful to have different vocabulary to describe the types of disease so that a relatively manageable issue like last year’s H1N1 would not fall into the same category of pandemic as a disease like HIV/AIDS. Given that H1N1 killed only 18,449 people last year, it is difficult to believe it needs to be given such a special classification when a normal seasonal influenza would often kill more than that and countless diseases around the world are comparable killers. Each of the top 10 most deadly infectious diseases kills >50,000 people annually. I believe the extra attention swine flu got was due in part to its concentration in the developed world and in part due to the fear that the disease would become a more deadly strain.
Both The Great Influenza and the case of last year’s swine flu are making me realize one of the great challenges of public health – striking a balance between ensuring all precautions are taken and keeping public fear to a minimum. In the 1918 flu, officials fell firmly on the side of doing too little, too late, while last year, officials quite possibly did too much.
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