College of Surgeons San Diego Inspiring Quality Forum P7


Dr. Eastman:

Should this become, Ralph, let’s talk about it here.  I know Sharp is represented here today.  One of the leaders in quality in this community for a long time, have a quality event.  A week from this morning, Scripps is having its fifth annual quality summit, and I would invite all of you if you are interested in coming.  It’s at the Del Mar Marriot at the same time.

It’s going to take a little different approach.  The title of that is “From the Genome to the Bedside,” but it talks about some of the issues.  The keynote speaker is Abraham Verghese, professor of medicine at Stanford, author of Cutting for Stone, and we’re going to have a panel where he is going to be paired opposite of Eric Toppel who’s just published a rather provocative book on the creative destruction of medicine.  It’s all about technology.

So, we’re going to have Abraham Verghese who talks about getting back to the basics, the stethoscope, and listening to the patients, and Eric Topol, a futurist, clinician, cardiologist, who says he hasn’t used a stethoscope in five years.  He thinks we should be using hand ultrasound and look at the heart.  You’re all invited.  If you want more information, we’d be happy to provide it.

Other questions?  Yes?


Scott Musikan:

Thank you.  I’m Scott Musikan.  I’m one of the vascular surgeons here in town.  I have a question about the concept of the electronic health record and the fact that it seems like unless there’s the integration of all the hospital systems with an electronic health record, costs are never going to be improved, information’s never going to be shared.

I mean we have patients that go from Sharp and get transferred over to Scripps, and you know all their studies are being repeated once they get there because they can’t see the information.  So, I want to know what’s being done to try to integrate the electronic systems so that costs go down and things are not repeated.


Chris Van Gorder:

That’s part of the government’s push to use meaningful health records.  There’s actually a time frame built in for information exchanges that will connect the systems together.  So, I, Sharp, Kaiser, and the government are working towards that point where we will be able to talk to each other.  That’s one of the requirements that we’ll use.


Dr. Hoyt:

One of the big debates is between the type of data you can get with risk-adjusted clinical outcome versus so-called administrative data.  One of the barriers is that it takes a NFTE in each hospital to collect clinical data, but we’re working very hard with EPIC, with the federal government, with several large medical record vendors to focus on a way in which EMRs can drive data directly into EMR systems so you can see a time in the future where the cost of actually sustaining these data systems would go way down because we get rid of a lot of the NFTEs.


Dr. Eastman:

We probably have time for one or two more questions, then I do want the panelists to have a change to make a final comment.


Dr. Tyner:

Jeff Tyner, a thoracic surgeon at Scripps.  As such we’ve been part of the STS database for quite some time.  My understanding is it’s the oldest single database system in medicine.  It has a lot of data, and it’s been a real treasure for us.  It’s allowed us to move extra patients sooner, reduce extra transfusion, and look at readmissions, all of which have reduced readmission costs but there’s two real issues we’ve identified along the way:  One is whoever gathers this data is very important.  I’m interested on how you plan on establishing that because there’s a huge difference in definitions and who gathers this information.  It really goes to the quality of the data.

The second issue as David Chang mentioned is that it’s very, very important.  Very few people from the public or probably in this room understand confidence limits or standard deviation.  So, when it comes to public reporting, you have to be very careful how you release this data, not that it shouldn’t be released, but it should be in some sort of palatable form.  I’m interested in how that’s being addressed.


Dr. Eastman:

David, you might want to speak to that, and certainly, any of the panelists that do.  Very important question.


Dr. Hoyt:

Yeah. I think with regard to the first part, we will see, but by formatting adequately, the field choices in electronic medical records, you can drive consistency in data entry.  That’s still theoretical, but that’s the hypothesis. In the meantime, NSQIP data is only reflected by trained nurses who are subsequently audited in the concurrence rate of [1:24:18], and it’s low.

I forgot the second question.  Public reporting.  We had a project with CMS, and, in fact, SCS, is part of that project as well.  SCS has been a leader in public reporting, and we’re working with consumer reports as I’m sure you’re aware, in developing metrics that are clear to the public but account for the variability that you’re talking about.  Consumer reports have done.

The second is CMS, and they’re looking very carefully at this as well.  On a prototype basis, you’ll start to see on a hospital compare website, those hospitals that want to post some of their NSQIP data as they get some experience.

The third opportunity, which is one of the strongest, is the California Healthcare Foundation obviously here in California.  It has put out an RFA to work to start putting out reports on three diagnoses:  Normal deliver, cancer, and, I believe, orthopedic procedures because their concept is that these are usually out in the distance a bit so there’s actually the opportunity for patients to shop around.  So, we’re probably going to work with them, in the cancer area to try to develop relevant metrics which would achieve the goal of public reporting.


Dr. Eastman:

Final question with Dr. Centurion.


Dr. Centurion:

Thank you, Dr. Eastman and Dr. Hoyt for all your leadership.  It’s a real bright shining light on San Diego’s contribution on the national level of surgical and physician leadership.  My question is on never events.  As you know never events are adverse episodes that occur in the hospital setting which Medicare will no longer pay.  These things include pressure sores, hospital-acquired infections, and falls.  It also includes DVTs, and I was at a forum in Dallas last where I had the chance to ask the medical director of CMS why it is that a hospital that is using A1 protocols for DVT prophylaxis starting the chemoprocess at the right time, using it in the right doses, at the right sequence, with no missed doses, and for the right period of time.  If that person gets a DVT, that’s a never event.  In other circumstance, if a person has no DVT prophylaxis or the DVT prophylaxis is administered inappropriately, that’s also a never event.

These things should be driving quality, not used as schemes for avoiding payment.  I asked him that exact question.  He said, “We don’t really care about quality.  We’re just trying to find out ways to save money,” and I would ask the American College of Surgeons to modify the way never events are being administered.  It is abjectly unfair to penalize a hospital for a never event when the patient care is perfectly organized around bedded protocols.


Dr. Eastman:

Thank you.  Everybody in favor raise your hand.  I think we all wrestle with that.  I hope in the area of surgery, that the College of Surgeons, the relationship with David Hoyt is building, we’ll see something else from the Joint Commission and people in Washington we can address that because it is blatantly unfair.  Hopefully, adhering to guidelines that are approved by people like the College of Surgeons will also be a defense in the whole medical liability issue that we haven’t discussed.

Well, in order to make our time limit, I would like to start with Dr. LaBelle.  I would just like each of you to make one point that you have heard today, questions you heard, something you didn’t get to say. Dr. LaBelle.


Dr. LaBelle:

I would just like to reiterate that even with the outcomes based data, it’s still a requirement of physician leadership to drive change in the system.


Dr. Chang:

I just want to thank that comment about patient informing, and again, I think the bigger message is we should learn to empower patients in this process. Again, this goes back to the eminence-based medicine. It’s not just medicine.  Patients also believe in that, and I think we could change that from eminence-based medicine on both sides to a more patient-drive, patient empowerment approach.


Dr. Schumacher:

I’ll say that NSQIP has given us a powerful tool and is the basis of quality improvement and being able to look at our data and look at our processes, but we don’t have to be afraid of the white elephant in the room of culture.  There is a systematic way to go about analyzing change in your culture, and I urge you, at your peril, not to ignore it.


Dr. Dilley:

Yes.  I’d just like to reiterate my last point.  It just takes one percent in surgical complications to have a very, very significant increase in quality and decrease in cost.  Every group should be able to figure out how to cut the post-operative complications by at least one percent and make that a goal for the year.


Dr. Eastman:

Dr. LaBelle, before we hear from the Captain, what is the waste in healthcare that if we decrease what is inappropriate will save?


Dr. LaBelle:

I think nationwide, the estimate is anywhere from $500 billion to $700 billion of waste in the system.


Dr. Kobelja:

For me, all hospital systems are integrated because patients move around.  We can’t lose sight of that.  Then, the question about the EHR spoke directly to that, us recognizing that the silo systems in military is just as bad at this as everybody else.  It is part of the problem, and we need to work at the leadership level to systemically break down those barriers.


Dr. Talamini:

My point would be with regard to the electronic health record, which UCSD made a major investment in five or six years ago, actually wen David Hoyt was still at UCSD.  Dr. Socha pushed this huge investment, inconvenient for the physicians, no question, but incredibly valuable when it came to quality improvement because of the data you can collect.

So, a related issue in our Center for the Future of Surgery, one of the approaches we’re trying to take.  My colleague Dr. Horgan makes the point that in a soccer game, if you commit one foul you get a yellow card.  If you get three, you get a red card, and you’re out.   Right now, with surgeons, for the State Board of California, there’s only a red card, and we need to figure out a way to retrain surgeons and help them at the yellow card stage.  I believe that we can do this in a place like we’ve created at Centers for the Future of Surgery.  I think it’s very important.


Dr. Eastman:

A very innovative concept.  Chris, you can have the last word.


Chris Van Gorder:

Okay.  Well, dudes.  I do market music every day, and I survey all the literature that’s out there about healthcare reform that I can get my hands on and managed in a day.  There are a lot of people out there saying that the sky is falling as it relates to healthcare.  I have never been more bullish about the future of healthcare.  I think we’re doing the right things.  I think we’re moving healthcare from sick to wellness.

It doesn’t mean we’re not going to have hospitals dealing with acutely ill patients.  Of course, we will, but I think we’re moving in the right direction.  I’ve never seen this level of collaboration in more than 30 years of healthcare administration, the doctors and administrators, all of us working together.  We’re actually going to improve the healthcare system, create more value for our patients and society.  So, I’ve never been more bullish.


Dr. Eastman:

Thank you, Chris, and I’ll take the opportunity to conclude by thanking Dr. Hoyt and the American College of Surgeons for allowing us to be the community to have the first forum West of the Mississippi, maybe and certainly the first on the West Coast that has to do with nepotism and Dr. Hoyt’s foundation here.

Dr. Cochrane, we really appreciate you being here as a physician-scientist who helped to train David Hoyt.  Thank you very much for a good one.

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