You are Number 1!

October 29, 2012

“We’re number 1!  We’re number 1!”  We heard that a lot after the summer Olympics, though not so much these days after a Packers game.  It doesn’t seem too incongruous at a sporting event, but I have to admit it feels kind of cheesy when applied to where we work.  And when it comes to the hospital, what exactly does it mean, anyway?  The last time Parents magazine did a ranking, in 2009, they rated CHW the third best children’s hospital in the country.  That felt pretty darn good.  (We are currently gathering data for their new survey, and hope to be ranked at least as highly.)  In the 2011 US News and World Report survey (we were unable to collect the necessary data to participate in 2012 because of the demands of preparing for Epic), we were not even among the top 10, though we ranked in the top 35 in all 10 specialties evaluated.  So what’s that about?  Part of it is that a large percentage (about one-third) of the US News ranking is based on “reputation,” which is at best subjective.  But perhaps it also reflects how hard it is to measure quality.

Not that it has stopped people from trying.  Whether it is or Angie’s list, which simply allows patients to post their anecdotes; proprietary services list MD Nationwide that pull together “data” on physician quality; or payers like United Healthcare’s Premium® designation, there is no shortage of ways for our “performance” to be reported on.

Even for the well-intended, one challenge is that quality is multi-dimensional.  I think we’re all pretty familiar with the IOM quality domains: effectiveness, safety, efficiency, timeliness, patient-centeredness, and equity.  Most providers have traditionally tended to emphasize effectiveness to the exclusion of other dimensions, but I believe that view has begun to change.   Even so, we tend to be skeptical of efforts to measure and report on quality (perhaps understandable given some of the sorry efforts already noted).  Some aspects of quality are things we can measure directly (e.g., cardiac surgery survival rates, central-line associated bloodstream infection rate, wait times, family satisfaction), others by (admitted imperfect) proxy (e.g., provider training and qualifications, staffing levels).  But in the end, even these things are problematic.  What are the best indicators of efficiency?  If there is a trade-off between two different aspects of quality, how do you decide which is more important?  The answers may depend in large part on one’s point of view.  Coming up with a simple composite that allows one to rate hospitals or providers seems, well, simplistic at best.

Or is it?  Perhaps, as Supreme Court Justice Potter Stewart famously said of pornography, “I cannot say what it is, but I know it when I see it.”  I rather like the definition provided by Louis Graff, an emergency physician: quality is “the care health professionals would want to receive if they got sick.”  So while I don’t want to minimize the importance of outside perspectives, regardless of what Parents magazine or US News ends up deciding (and I do appreciate those who have worked to gather the data for those surveys!!), I know that what I see every day at Children’s meets that last definition of quality.  You are number 1!

Countdown to D-Day

October 22, 2012

OK, I admit it – it’s only 12 days until Epic go-live, and since I am working in the ED starting at 8 am on D-Day (11/3), I admit I am nervous.  Rationally, I know the universe isn’t going to implode.  But realistically, while I’ve tried to be the voice of optimism, I know there are things that are going to be painful, or worse.  I’m especially worried about the wait times.  When things grind to a halt because of a prolonged resuscitation, families understand there is something up, and they cut us some slack.  But will they tolerate waiting longer because we’re trying to figure out how to enter their chief complaint, or record their allergies, or even how to turn the thing on?  How long will they tolerate it?

For those of you who missed the annual Rebecca Jayne Memorial Lecture Grand Rounds on 9/28/12, I urge you to watch it onlineDr. Lalit Bajaj, an emergency physician from Colorado Children’s, who has been using Epic for 8 years, talked about the EHR: The Good, The Bad, and The Ugly.  I was pleased at the level of relative confidence and optimism the listeners expressed about our own impending implementation using the audience response system.  But Lalit’s message was frankly, if not surprisingly, mixed.  Here were some of the take away messages:

  • Short term we’ll mostly notice the pain: most things will take longer; patients will wait longer; some types of errors will be harder to make but other types will be easier (I loved his anecdote about the 4 year old girl with normal penis and testes documented on the exam).
  • The longer term benefits are significant, but will take some work.  We can learn from others about how to get the most bang for our buck during optimization.  For example, they found that putting a lot of time into developing group templates was not worth it, since everyone wanted their own.  However, using structured data elements was critical to getting the most out of Epic’s ability to measure and ultimately improve quality, not to mention conducting research – as this article shows.
  • Understanding our workflows is the key to getting the most out of Epic.  Teams should consider practicing together in the playground in advance and doing pre-go-live personalization as a team.
  • Decision support is really cool, but will probably take longer to achieve than we’d like.  Patience is a virtue.  And when you get “alert fatigue”, don’t yell at the computer; make a note to add that to the optimization queue.

 As Lalit said, the EHR works for us, we do not work for it.  We just need to work to make that happen.

-Marc Gorelick, MD,

Starting with Curious

October 15, 2012

Michel de Montaigne (1533-1592), arguably the world’s first blogger, wrote of his monumental Essays, “I am myself the matter of my book.” A tad egotistical, perhaps, but also disingenuous. In reality, his writings were about everything under the sun. (If he had had the benefit of hyperlinks, we might not need Wikipedia or any other written works.)

My goals in starting this blog are both more modest and, I hope, less self-centered. Unlike some bloggers, I’m not particularly looking for an opportunity to talk about myself, or to vent or rant (not that a bit of that could creep in occasionally). I’m looking for another way to share information that I think is important for CSG and its members – information about the practice and our partners, and about the larger health care environment. Ideally, this will not only enlighten but stimulate thought and curiosity about what we are doing, where we are heading, and how we can all contribute. Curiosity, as we have learned in our work on Culture, is the starting point for constructive thinking, healthy interactions, and ultimately excellent results. And this is meant to be an interactive, multi-way conversation; please use the Comments feature liberally.

While you may see entries on a wide range of topics, I’ll try to concentrate on what I see as our “blue chips” – those things that are vitally important to our success, the things we need to maintain our focus on. Each of us has our own blue chips, but the blue chips for the practice are:

  •  iStrategy, especially Epic implementation, stabilization, and optimization
  • Leadership transition in the Department of Pediatrics and leadership development and succession planning across the practice
  • Adapting our business and care models to meet the rapidly evolving health care environment

-Marc Gorelick, MD,

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