Medical Staff

Global change is underway in healthcare

Medical Staff Affairs Monthly, January 22, 2007

We have entered the seventh year of the 21st century and I am impressed at how quickly old practices and long-standing obstacles to better healthcare are being swept away by the tides of change. One sea change is the marked acceleration in hospital employment of doctors. Not only are hospitals seeing this as a defensive tactic, but physicians are embracing these opportunities and starting to explore in greater numbers the strengths of multi-specialty group practice. The challenge for hospital medical staffs will be to figure out how to co-exist with dominant hospital-owned physician practices and take advantage of the strengths such organizations can bring to their work. At the same time, such medical staffs will need to address the fears of independent physicians on the staff and assure all parties that credentialing and peer review will be performed at all times with integrity.

Progress is picking up on the adoption by physicians and hospitals of electronic health records and they are increasingly proving an advantage in providing the data to demonstrate quality. Such data, in turn, is achieving superior reimbursement for some physicians under pay for performance schemes. These changes notwithstanding, it is impressive how far behind we are compared to more effective and less expensive health systems in other countries. For example, the journal Health Affairs recently reported the following comparative data regarding primary care physicians based on the Commonwealth Fund's 2006 International Health Policy Survey:

  • Adoption of health information technology. Only about a quarter of primary care doctors in the U.S. (28%) and Canada (23%) use electronic medical records, compared with a large majority of doctors in the Netherlands, (98%), New Zealand (92%), the U.K. (89%), and Australia (79%).
  • Receipt of computerized alerts for potentially harmful drug doses or interactions. Less than a quarter of U.S. primary care doctors (23%) receive such alerts, compared with 40 percent of primary care doctors in Germany and 93 percent in the Netherlands. Among the surveyed countries, only in Canada (10%) do physicians make less use of computerized alerts than do U.S. physicians.
  • Availability of financial incentives for improving quality. Just 30 percent of U.S. primary care doctors reported receiving or having the potential to receive any incentives for managing chronic disease, achieving clinical quality targets, enhancing preventive care, or any other quality improvement activities.

We may be behind but we have seen the light and progress is afoot. However, some things don't change. Our hospitals continue to be plagued by "disruptive" physician conduct and the newly named Joint Commission (which will no longer go by the unwieldy acronym JCAHO) is considering a standard to address this concern. (Input can be provided The Joint Commission on this draft standard at http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards/FieldReview/disruptive_behavior_hap_stds.htm

The Joint Commission has also implemented new credentialing standards for 2007 and the renewed exhortation to rigor in this important activity may be particularly timely given an article posted on the website of The Journal of Forensic Science.Researcher's reported in the article their survey results which linked more than 2,100 suspicious deaths worldwide to 54 doctors and nurses convicted of serial murders or lesser charges since 1970. Ken Kizer, the noted safety expert and former head of the Veterans Health Administration noted that "The problem is bigger than anyone would like to think." In this column previously I have noted the new pressures on hospitals to share information about practitioners with other institutions when it is properly requested. A seminal court case in this regard is that of Kadlec v. Lakeview which suggests that hospitals may have an obligation to give full and truthful information. A growing number of states (e.g., Pennsylvania and New Jersey) have passed laws to shield hospital from lawsuits if they provide truthful job references.

On a positive note, California is now a safer place for physicians to conduct appropriate peer review and hold one another accountable for safe and good quality care and conduct. This is because a California procedural law designed to quickly screen out meritless claims that chill the exercise of constitutionally protected speech also may be applied to strike down harassing lawsuits filed in response to medical peer-review proceedings. This was the conclusion of the California Supreme Court in a recent ruling (Kibler v. Northern Inyo County Local Hospital District, Cal., No. S131641, 7/20/06).  The ruling determined that hospital peer review proceedings constitute "official proceeding[s]" under the state's anti-Strategic Lawsuit Against Public Participation, or anti-SLAPP, statute. While I often hear complaints from physicians about "sham peer review," I believe the much bigger problem lies with the inevitable lawsuits against hospitals and peer review committees whenever they properly impose corrective action on a member of the medical staff. I am pleased that, as I travel the country and work with numerous medical staffs, I rarely find that the threat of such lawsuits has dissuaded physicians from engaging in important peer review activities.

We are now well into the heart of winter across the country and one thing 2007 has brought us is strange weather--from unusual balminess in much of the country to rare winter "hurricanes" and deadly ice storms in other parts. The turbulence in the weather seems to coincide with the global climate change that is underway. Global change is underway in health care as well and its pace is picking-up. We can all expect a turbulent year ahead.

Best regards,
Todd Sagin, M.D., J.D.
National Medical Director
The Greeley Company

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