Tag: Patient Trends
A study by researchers at Johns Hopkins Medicine says medical errors should rank as the third leading cause of death in the United States — and highlights how shortcomings in tracking vital statistics may hinder research and keep the problem out of the public eye.
The authors, led by Johns Hopkins surgeon Dr. Martin Makary, call for changes in death certificates to better tabulate fatal lapses in care. In an open letter, they urge the Centers for Disease Control and Prevention to immediately add medical errors to its annual list reporting the top causes of death.
Based on an analysis of prior research, the Johns Hopkins study estimates that more than 250,000 Americans die each year from medical errors. On the CDC’s official list, that would rank just behind heart disease and cancer, which each took about 600,000 lives in 2014, and in front of respiratory disease, which caused about 150,000 deaths.
Medical mistakes that can lead to death range from surgical complications that go unrecognized to mix-ups with the doses or types of medications patients receive.
But no one knows the exact toll taken by medical errors. In significant part, that’s because the coding system used by CDC to record death certificate data doesn’t capture things like communication breakdowns, diagnostic errors and poor judgment that cost lives, the study says.
“You have this overappreciation and overestimate of things like cardiovascular disease, and a vast underrecognition of the place of medical care as the cause of death,” Makary said in an interview. “That informs all our national health priorities and our research grants.”
The analysis was published Tuesday in The BMJ, formerly the British Medical Journal.
Bob Anderson, chief of the mortality statistics branch for the CDC, disputed that the agency’s coding is the problem. He said complications from medical care are listed on death certificates and that codes do capture them.
The CDC’s published mortality statistics, however, count only the “underlying cause of death,” defined as the condition that led a person to seek treatment. As a result, even if a doctor does list medical errors on a death certificate, they aren’t included in the published totals. Only the underlying condition, such as heart disease or cancer, is counted, even when it isn’t fatal.
Anderson said the CDC’s approach is consistent with international guidelines, allowing U.S. death statistics to be compared with those of other countries. As such, it would be difficult to change “unless we had a really compelling reason to do so,” Anderson said.
The Johns Hopkins authors said the inability to capture the full impact of medical errors results in a lack of public attention and a failure to invest in research. They called for adding a new question to death certificates specifically asking if a preventable complication of care contributed.
“While no method of investigating and documenting preventable harm is perfect,” the authors write, “some form of data collection of death due to medical error is needed to address the problem.”
Anderson, however, said it’s an “uncomfortable situation” for a doctor to report that a patient died from a medical error. Adding a check box to the death certificate won’t solve that problem, he said, and a better strategy is to educate doctors about the importance of reporting errors.
“This is a public health issue, and they need to report it for the sake of public health,” he said.
Dr. Tejal Gandhi, president of the National Patient Safety Foundation, said her organization refers to patient harm as the third leading cause of death. Better tracking would improve funding and public recognition of the problem, she said.
“If you ask the public about patient safety most people don’t really know about it,” she said. “If you ask them the top causes of death, most people wouldn’t say ‘preventable harm.’ ”
Dr. Eric Thomas, a professor of medicine at the University of Texas Houston Medical School whose research was cited in the Institute of Medicine’s landmark To Err is Human report, said existing estimates aren’t precise enough to support immediately listing errors as the third leading cause of death.
But collecting better cause-of-death data is a good idea, said Thomas, who agreed that medical errors are underreported.
“If we can clarify for the public and lawmakers how big a problem these errors are,” he said, “you would hope it would lead to more resources toward patient safety.”
Google Glass is no longer being marketed to consumers, but its enterprise business continues to pick up pace, and today one of the more promising companies developing medical services using Google’s connected eyewear is announcing a significant investment in its technology, which aims to “re-humanize the interaction” between doctors and patients by pulling physicians’ faces away from their computer screens, according to its CEO.
Augmedix, a startup out of San Francisco that has developed a platform for doctors to collect, update and recall patient and other medical data in real-time, has raised $17 million in a strategic round.
The investment is significant because of who is making it: it comes from five of the biggest healthcare providers in the U.S. — Sutter Health, Dignity Health, Catholic Health Initiatives (CHI), TriHealth Inc., and a fifth that is remaining unnamed for now. Together, these groups — which operate hospitals and other facilities, and in other aspects compete against each other for business in the healthcare industry — cover about 100,000 doctors and other healthcare providers and millions of patients. The idea will be for Augmedix to supply these physicians and other staff with their connected eyewear.
This investment comes after a Series A but before a full Series B (which CEO Ian Shakil said in an interview is not being raised right now), and it brings the total raised by Augmedix to $40 million. After its last round of $16 million, Augmedix was valued ataround $100 million, and while Shakil is not disclosing the valuation of the company, he told me that this was a “healthy up-round.” From what I understand, the valuation is between $120 million and $160 million, closer I think to the latter of the two.
One of the big criticisms of Google Glass (among other wearables) has been that devices that you put on your face can alienate you from people you are interacting with — both because they put people off, and also because they distract you, the wearer, from focusing on the person in front of you.
Ironically, it seems that the exact opposite of this is the reason behind Augmedix’s growth to date. Shakil noted that one of the big problems today in U.S. medical systems is the amount of data that doctors and others on the medical team are required to reference and input for each patient.
“When you are with doctors without Glass, they are charting and clicking on computers for a lot of the time, and not focusing on their patients,” he said. “When you put on Google Glass to collect and reference that information, it helps you engage with the patient better.” Shakil added that the Augmedix system “takes care of documentation in the background faster than you would. It humanises the process.”
This is also what attracted the strategic investors it seems, even to the point of putting in money alongside competitors.
“At Dignity Health, we are committed to developing partnerships that harness the great potential of technology and apply it in ways that help patients and providers make better day-to-day decisions about care,” said Dr. Davin Lundquist, chief medical information officer, Dignity Health, in a statement. “The use of Google Glass and Augmedix allows our doctors to spend more time with patients by eliminating the distraction of entering information into a patient’s electronic medical record on the computer. This enables our healthcare providers to give more focused attention to our patients and results in a better patient experience.”
“As we strive to create the high-quality, high-value healthcare experience our patients expect from Sutter Health, new technology tools and services allow us to innovate in ways that deliver a more efficient, affordable and personalized level of care,” said Dr. Albert Chan, Sutter Health’s vice president, chief of digital patient experience, also in a statement. “Wearable technology holds tremendous promise, especially for enhancing the office visit experience. We are committed to partnering with our patients, and value how our growing network of digital health innovators helps strengthen those patient-doctor relationships in new ways.”
Interestingly, the humanizing doesn’t end at the patient end of the system. The software that Augmedix currently uses relies on a large team of humans to help enter info and update records in the back end. “It’s almost more powered by humans than AI and speech recognition today,” Shakil said.
However, he added that part of the funding is going to build out more of the tech using some of the later innovations in the field: “We will be deploying more natural language processing in the future. It creates more efficiencies for us to do so.” That may be using tech from Google (which is ramping up in this space), but just as likely Augmedix will consider solutions from Nuance and others, he said.
Google Glass always felt and continues to feel somewhat like a niche play, so just how big is Augmedix today? Today there are “hundreds” of doctors already using Augmedix’s software on Glass, concentrated in Southern and Central California, Shakil said. That may not sound like a lot, but Shakil points out that each doctor pays “low-single digit thousands of dollars” each month, which works out to a “very reasonable” amount of annual revenue.
He said the company is on track to have thousands of doctors using this by next year, with the bigger target for 10,000 doctors within five years. Considering that these five new investors cover 100,000 doctors and other practitioners, and the amount of outlay that’s already dedicated to IT in the medical industry, a ten percent penetration rate doesn’t sound too outlandish.
Currently, Glass is at the center of what Augmedix does today, but it sounds like this isn’t something the company is necessarily wedded to for the long term. Indeed, while Google was something of an early mover with Glass (cleverly lowering the bar for building solutions with its Enterprise edition), the world has moved on when it comes to connected headsets that feed its users information. Hardware now includes other smart eyewear to full-on augmented reality and virtual reality gear from the likes of Facebook’s Oculus, Meta, Microsoft, Samsung and more.
Shakil says that for now its solution and business is focused on Glass (note: among other VCs like DCM and Emergence, Google itself has not invested in Augmedix). But it is also testing other alternatives in what Shakil refers to as “light AR.”
Down the line, Augmedix wants to add more services on to its platform to better complete the loop. This will include patient-oriented features, “so that the patient can go home and relive the visits and listen again to what the doctor said” or be taken through demonstrations for self-care.
Augmedix also wants to add more guidance for doctors, to help them remember different points for, say, smoking cessation regiments or other clinical work. Way further down, you could imagine how this might extend into other aspects of a doctor’s work, such as during procedures.
The diagnoses of 27.3 percent of patients with depression and 27.7 percent of patients with bipolar disorder were missing from their primary care electronic health records, a study published in the Journal of the American Medical Informatics Association has found.
These behavioral health patients had an average of three to eight visits during the year both at the EHR site and outside the site. But despite these high numbers, the data from the encounters were underreported.
In the study, researchers from the Department of Population Medicine at Harvard Medical School studied Harvard Pilgrim Health Care patients at Harvard Vanguard Medical Associates who in 2009, who had a depression or bipolar diagnosis. Researchers studied outpatient care visits and calculated the proportion of these visits not found in the EHR.
“In this research, we found the lack of integration, interoperability and exchange in US healthcare resulted in a major EHR missing roughly half of the clinical information,” the authors wrote. “While behavioral healthcare is unique, it’s important to emphasize our findings demonstrate the problem of incomplete clinical data in the EHR is not limited to behavioral care.”
About half of the outpatient care days from insurance claims could not be matched to clinical contacts recorded in the EHR, the report shows. While this data is true for all areas of care, the extent of missing information was greater for behavioral services than for general outpatient.
Furthermore, 89 percent of acute psychiatric services in hospital-based events were missing from the EHR, and 43 percent of all hospital-based events were missing. In contrast, clinical events found in the EHR could be matched to claims 93 to 98 percent of the time.
The study also found there were also high rates of missing EHR data in general for healthcare, both for inpatient and outpatient care. Areas of specialist care were also grossly underrepresented in primary care EHRs.
“Published reports touting the anticipated benefits of the recent rapid adoption of EHRs should be tempered by frank examinations of EHRs as they currently exist,” the authors said. “Individual providers and health system leaders need to be fully cognizant of the information gaps and disconnects that lie behind the screen.
“Features intended to improve care and protect patients from harm may be inadequate in typical fragmented health systems, offering false comfort,” they added
Although EHR use offers a wide array of benefits, including increased care coordination and lower healthcare costs, a recent survey shows that perhaps these digital systems are not being utilized to their fullest potential.
The Connected Care and the Patient Experience survey, commissioned by Surescripts and conducted by Kelton Global, shows that a majority of patients are not seeing advancements in electronic healthcare delivery. According to the survey, nearly 55 percent of respondents find their patient histories are missing or incomplete.
Furthermore, approximately half of patients state their physicians do not know which prescriptions they are taking, 61 percent state their physicians to not know which allergies they have, and approximately 40 percent state that their doctor’s office does not have their personal or insurance information on file.
The survey also shows that 29 percent of patients are often charged with sharing their medical information, test results, and other information from physician to physician. Furthermore, 40 percent report great difficulty accessing their own health records.
The survey shows that patients take notice, and are frustrated by, the hurdles they face in accessing health records. Half of respondents state that renewing their driver’s license would require less paperwork than a doctor’s office visit. Additionally, over half of respondents state that visiting the doctor’s office is equally frustrating as buying a new car.
Patients reportedly take notice of the prevalence of paperwork inside of the physician’s office, as well. Over half of respondents report signing paperwork and having their health insurance card or ID scanned during each visit, and nearly 30 percent are charged with filling out personal or medical information on paper each visit.
The study shows that this increased paperwork takes valuable time away from the patient visit. On average, respondents reported spending five minutes filling out paperwork, and six minutes verbally sharing patient information. This review of patient information consumes approximately 11 minutes of the average 15-minute appointment. Because of this, 49 percent of respondents arrive early to doctor’s appointments and 28 percent have appointments scheduled with extra time built in to account for paperwork.
Respondents also report preferring and having more confidence in a physician who uses technology to enhance his or her healthcare delivery. Nearly 40 percent of respondents state that they would be more likely to recommend a physician who utilized EHRs, and 36 percent state that EHR use would make them less likely to switch to a new physician. Furthermore, when faced with two doctors of equal skill, over half of respondents would select the one who allowed them to fill out information online prior to an appointment, receive test results online, store medical records electronically, and schedule appointments online.
Patients also tend to have more confidence in physicians who utilize EHRs and other technology, the survey shows. For example, nearly half of respondents report an increased likelihood to communicate with their physician more openly if they were able to text message or email their physician with concerns. Additionally, patients reportedly feel more at ease at practices that utilize technology for administrative tasks. Forty percent of respondents report that physicians who use computers or tablets or more innovative, 33 percent feel they are more competent, and nearly 70 percent feel they are more organized and efficient.
Surescripts officials state that these gaps in electronic healthcare are a major detriment to the industry. In order to achieve goals of increased quality of care, patient experience, and lowered cost of care, EHRs and other electronic health tools need to be utilized to their potential.
“Dangerous voids in health information sharing can easily be solved through the use of digital communications and technology,” says Chief Executive Officer of Surescripts Tom Skelton in a press release. “This survey proves patients take notice and are ready for a change. As an industry, we need to come together to connect the nation’s healthcare system — to enhance the patient experience while improving quality and lowering the cost of care.”
Dental patients really don’t like Western Dental. Not its Anaheim, Calif., clinic: “I hate this place!!!” one reviewer wrote on the rating site Yelp. Or one of its locations in Phoenix: “Learn from my terrible experience and stay far, far away.”
In fact, the chain of low-cost dental clinics, which has more Yelp reviews than any other health provider, has been repeatedly, often brutally, panned in some 3,000 online critiques — 379 include the word “horrible.” Its average rating: 1.8 out of 5 stars.
Patients on Yelp aren’t fans of the ubiquitous lab testing company Quest Diagnostics, either. The word “rude” appeared in 13 percent of its 2,500 reviews (average 2.7 stars). “It’s like the seventh level of hell,” one reviewer wrote of a Quest lab in Greenbrae, Calif.
Indeed, doctors and health professionals everywhere could learn a valuable lesson from the archives of Yelp: Your officious personality or brusque office staff can sink your reputation even if your professional skills are just fine.
“Rudest office staff ever. Also incompetent. I will settle for rude & competent or polite & incompetent. But both rude & incompetent is unacceptable,” wrote one Yelp reviewer of a New York internist.
ProPublica and Yelp recently agreed to a partnership that will allow information from ProPublica’s interactive health databases to begin appearing on Yelp’s health provider pages. In addition to reading about consumers’ experiences with hospitals, nursing homes and doctors, Yelp users will see objective data about how the providers’ practice patterns compare to their peers.
As part of the relationship, ProPublica gets an unprecedented peek inside Yelp’s trove of 1.3 million health reviews. To search and sort, we used RevEx, a tool built for us by the Department of Computer Science and Engineering at the NYU Polytechnic School of Engineering.
Though Yelp has become synonymous with restaurant and store reviews, an analysis of its health profiles shows some interesting trends. On the whole people are happy — there are far more 5-star ratings than 1 star. But when they weren’t, they let it be known. Providers with the most reviews generally had poorer ratings.
Of the top 10 most-reviewed health providers, only Elements Massage, a national chain, and LaserAway, a tattoo and laser hair removal company with locations in California and Arizona, had an average rating of at least 4 stars.
Western Dental did not return phone calls and emails seeking comment.
Dennis Moynihan, a spokesman for Madison, N.J.-based Quest Diagnostics, said the company has more than 2,200 patient service centers around the country and had 51 million customer encounters last year. He said all feedback is valued.
“While one negative customer experience is one too many, we don’t believe the numbers presented are representative of the service that a vast majority of our customers receive every day,” he said.
For years, doctors have lamented the proliferation of online rating websites, saying patients simply aren’t equipped to review their quality and expertise. Some have gone so far as to threaten — or even sue — consumers who posted negative feedback.
But such reviews have only grown in popularity as consumers increasingly challenge the notion that doctor knows best about everything. Though Yelp’s health reviews date back to 2004, more than half of them were written in the past two years. They get millions of page views every month on Yelp’s site alone.
In many ways, consumers on Yelp rate health providers in the same way they do restaurants: on how they feel they’ve been treated. Instead of calling out a doctor over botched care or a possible misdiagnosis (these certainly do happen), patients are far more likely to object to long wait times, the difficulty of securing an appointment, billing errors, a doctor’s chilly bedside manner or the unprofessionalism of the office staff.
Health providers as a whole earned an average of 4 stars.
But sort by profession and the greater dissatisfaction with doctors stands out.
Doctors earned a lower proportion of 5-star reviews than other health professionals, pushing their average review to the lowest of any large health profession, at 3.6. Acupuncturists, chiropractors and massage therapists did far better, with average ratings of 4.5 to 4.6.
Other providers, like dentists and physical therapists, are “actively seeking out customers to review them, whereas doctors have a lot of antipathy toward reviews and as a result have been trying to suppress reviews for many years,” said Eric Goldman, a professor at Santa Clara University School of Law and co-director of its High Tech Law Institute. He has written extensively about physician review websites and physician arguments against them, but did not review the Yelp data.
Doctor visits also tend to be more complex than visits to the dentist or chiropractor. A typical dental visit is for a specific service — a teeth cleaning, a cavity filled or a root canal. In general, expectations are clear, and ways to gauge success are easier than with a doctor visit.
Healthgrades, a site which focuses solely on health providers, also sees slightly lower ratings for doctors than for dentists and other health providers, though the differences are smaller than those on Yelp.
Unlike Yelp, Healthgrades, which says it has 6 million survey scores, has not allowed consumers to post comments. But Evan Marks, Healthgrades’ chief strategy officer, said the health rating systems are in their infancy. Soon, he said, patients could see different questions based on the type of doctor they see to provide far more useful feedback to those searching the site.
None of this has yet gained favor with physicians. The American Medical Association encourages patients to talk to their doctors if they have concerns, not post views anonymously. And those looking for doctors should be similarly skeptical, the group says in a statement. “Choosing a physician is more complicated than choosing a good restaurant, and patients owe it to themselves to use the best available resources when making this important decision.”
The AMA has called on all those who profile physicians to give the doctors “the right to review and certify adequacy of the information prior to the profile being distributed, including being placed on the Internet.”
In 2012, the group partnered with a company called Reputation.com to offer discounts to doctors for a service that monitors their online presence and tries to combat negative reviews.
Western Dental’s average rating of 1.8 stars on Yelp is well below the average of 4 for all dentists nationwide. About 1,250 of its 3,000 reviews used the words “wait” or “waiting” and about 15 percent of them, the word “worst.”
When patients leave angry comments, the chain’s “social media response team” often replies, inviting patients to call or email and citing a federal patient privacy law known as HIPAA for not responding in more detail. “Thank you for reaching out and providing the opportunity to improve our services. We hope to speak with you soon,” the notes say.
At least one patient gave a Yelp follow-up review of the social media response team’s performance: “I responded to the info in their response twice and got no reply at all … they are just attempting to minimize the PR damage caused by undertrained and rude, lazy staff.”
Periodically doctors, dentists and other providers threaten or even file lawsuits against people who post negative reviews on Yelp or against Yelp itself. Their track record is poor: Courts have ruled in favor of the company and various consumers.
In June, New Jersey resident Christina Lipsky complained in a 1-star review on Yelp that Brighter Dental Care had recommended $6,000 worth of work that a another dentist subsequently determined was unnecessary.
Within days, she received a letter from a lawyer who said he was retained by Brighter Dental “to pursue legal action against you and all others acting in concert with you.” The letter was signed by Scott J. Singer, an attorney whose office is in the same building as a Brighter Dental clinic. A man named Scott Singer was also listed in 2012 as the non-clinical chief executive officer of Brighter Dental. Singer did not return a call or email seeking comment.
After Lipsky took her story to local media, Singer sent her a letter saying Brighter Dental was dropping its legal pursuit. In an email to ProPublica, Lipsky said “People put a lot of trust into their health care providers, and if my review could help others make an informed decision regarding their treatment, then it was worth it.”
Expanding blood pressure screenings to non-primary care settings can help identify more patients with hypertension, and could contribute to better hypertension control and management.
That is the finding of a Kaiser Permanente study of more than one million patients’ electronic health records published in the Journal of Clinical Hypertension.
The researchers analyzed the records of 1,076,000 Kaiser Permanente Southern California patients seen over a two-year period in primary care settings and non-primary care settings, including optometry, orthopedics and urology. The study reported the prevalence of hypertension and compared the characteristics of those patients identified with hypertension in a non-primary care setting to those identified in primary care settings.
Of the patients studied, 112,000 were found to have high blood pressure by the end of the two-year study period. Of these, 83 percent were diagnosed in a primary care setting and 17 percent in a non-primary care setting. The main non-primary care specialties to first identify a high blood pressure reading were ophthalmology/optometry with 25 percent, neurology with 19 percent, and dermatology with 13 percent. All staff members conducting blood pressure screenings in these clinical settings were certified in blood pressure measurement to ensure consistency in screenings.
According to the researchers, the number of false positives were comparable between both settings, suggesting that blood pressure readings in non-primary care settings were as accurate as those taken in primary care settings. Patients who were screened in non-primary care settings and found to have high blood-pressure readings were sent back for follow-up visits with their primary care provider.
“Patients who do not see their primary care providers on a regular basis may have hypertension that goes unrecognized,” said study lead author Joel Handler, M.D. “For this reason, expanding hypertension screening to non-primary care settings may be an opportunity to improve early hypertension recognition and control.”
The study indicated that patients identified with hypertension during non-primary care visits were more likely to be older, male and non-Hispanic white. In addition, these patients were also more likely to smoke and to have chronic kidney disease. Researchers also found that patients with an initial high blood pressure identified during non-primary care were less likely to be obese compared to those with an initial high blood pressure identified during a primary care visit.