By Roy Poses, MD

While primary care falters in the US, those who teach it seem to feel increasingly poverty stricken.  Now it appears that one reason for this is an amazing example of multiple failures of transparency and accountability.  Let me work through it, begging your pardon for a little bit of “inside baseball,” medical education style.  The results suggest how we desperately need some medical disciples of Sherlock Holmes.

Background
My personal experience and increasing data suggests that most medical school faculty believe that their teaching is not valued by their institutions because teaching brings in no external funds.  In 2004, Dr Catherine DeAngelis, then the editor of JAMA, wrote “few medical schools provide adequate, if any, reimbursement for teaching time.”(1)  (See this 2005 post.)   This seems absurd on its face, since what are medical schools for if it is not to provide teaching.

However, there is evidence of this mission-hostile behavior.  In 2007, we quoted from a revealing interview with Dr Lee Goldman, Executive Vice President for Health and Biomedical Sciences at Columbia University,(2) who stated that “taxpayers,” faculty who “generate more [money] than they cost,” are valued most, and implied that faculty who focus on teaching are regarded as “welfare recipients,” who bring in less external funding, and are valued least.  In 2010, we noted the results of a large-scale survey presented by Dr Linda Pololi in which 51% of faculty felt that the administration only valued them for the money that they brought in, and half felt that their institutions did not value teaching.(3)
Yet while faculty seem to believe that educational institutions receive little if any money to pay for teaching, it is not clear why the believe something so counter intuitive, and it is less clear what money actually goes to pay for medical education.

US Government Funding for Graduate Medical Education
However, several recent publications affirm that actually a lot of money goes towards one important form of medical education, yet the specifics of the money flows are shrouded in secrecy.  In the May, 2012, SGIM Forum, Dr Mark Liebow and colleagues summarized some of what is known about federal support of graduate medical education, that is, education of interns, residents, and other house officers.(4)  There are two streams of money that flow from Medicare to US hospitals:

Direct GME (DGME) payments help hospitals pay the salaries of residents, teaching faculty, and support staff. DGME is the product of three numbers: a per resident amount that varies by hospital, adjusted annually for inflation; the number of residents in the hospital (capped for each hospital at 1997 levels); and the fraction of discharges from the hospital that are Medicare beneficiaries.

The Indirect Medical Education (IME) payment is a percentage amount added on to each DRG payment. The percentage is calculated via a complex formula (the only US statute containing an exponent!), where the key factor is the ratio of interns/residents to beds (IRB ratio).

These two streams are of considerable size:

Of the $9.2 billion Medicare paid for GME in 2010, $3 billion was for DGME and $6.2 billion for IME. The money is paid to hospitals sponsoring training programs rather than to the training programs or other hospitals where training occurs. While about 1,100 hospitals receive GME payments, 66% goes to the 200 hospitals that have the largest numbers of residents.

So, the 200 largest hospitals get about $2 billion in direct GME money (and presumably about another $4 billion in indirect money). This averages then to about $10 million DGME and $20 million indirect GME per hospital.

Thus, teaching, at least the teaching of interns, residents, and other house-staff does pay, and much more than trivial amounts. (Note that these amounts are not for teaching of medical students, which ought to be supported by other funding streams.)
Why then do faculty think that teaching does not bring in any money?

The GME Money Vanishes
An article by Dr Saima I Chaudhry and colleagues in the American Journal of Medicine begins to explain, although the explanations are found between the lines.(5)
First of all, while the graduate medical education money is paid by the government to the hospitals, the government does not publish what it pays to individual hospitals:

It has been previously reported that the amount of GME funding individual hospitals receive is not publicly reported by the Centers for Medicare and Medicaid Services,….

The government also does not hold the hospitals accountable for how they spend this money, nor for the quantity or quality of education they supply in exchange for it.
Remarkably, Chaudhry et al imply that that the people who run graduate medical education teaching programs also may not know how much money their hospitals receive from the government to fund their programs. The introduction to their article noted:

It is unclear how much program directors know about the amount and flow of DME funds to their programs. Program directors’ beliefs about the transparency of funding to their programs, or their desire to influence how funds are distributed to them, also are unknown.

The article reported on a survey of internal medicine residency program directors which asked about “their knowledge of D[G]ME funding for their programs, the transparency with which funds are distributed to them, and their desire to influence this disbursement.” The researchers sent surveys to 372 member programs, representing 97.1% of all US internal medicine residencies. They got 268 responses, a 72.0% response rate.
The main results were that only 159/268 (59.3%) of program directors had tried to find out how much DGME money their programs received, and of those, only 84 (52.8% of those enquiring, but only 31.3% of all respondents) actually knew how much money their programs got.

Of the 92 program directors who did not even try to discover how much money their programs received, approximately 21% said that “no one would tell me,” 21% said that the “information would be inaccurate,” 14% said they “don’t know who to ask,” and 2% were “afraid to ask.”

Summary
US medical school faculty, especially those in primary care, increasingly feel pressured to perform activities that they perceive brings in money from external sources. They tend to believe that their own teaching somehow does not bring in any money, and that their careers will fail if they do not put more emphasis on other activities that the institution views as more profitable.

However, literally billions of US government dollars go to support the education of house staff, including the salaries of faculty who teach interns and residents, who probably are the majority of physician faculty. Faculty probably do not know this, because the government does not publish the amounts given to individual hospitals, nor demand of the hospitals any accountability for how they spend the money they receive.

Presumably, the top executives of each hospital know how much money the government gives them. Nonetheless, the majority of physician leaders of residency programs are never told these amounts, apparently because their hospital executives kept the amounts secret. Many of those educators who have tried to find out the figures were unsuccessful. Some did not even try to find out based on beliefs that their attempts would be unsuccessful, any amounts they discovered would be inaccurate, the people who knew the amounts were hidden, or that it would be dangerous to their careers to even try.

Thus billions of dollars of money flowing from the government to fund graduate medical education seems to have vanished in an amazing example of widespread deficiencies in accountability and transparency.

There are many people who blame government for many social ills. In this case, one can blame the US Congress for not writing a law that makes the money flows transparent and hospitals accountable for providing good educational value for the money provided. One can also blame the executive branch, particularly the Center for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services (DHHS) for not making the money flows and the values received for them transparent.

There are a few people, including this author, who also blame the leadership of health care organizations for many of the problems besetting health care. In this case, one can blame top leadership, presumably CEOs and chief financial officers (CFOs) of hospitals for hiding the amounts of money they receive from Medicare to finance graduate medical education. One can also blame the physician leaders of residency programs for not insisting that they know the true sources of financial support for their programs, obtain budgets that reflect this support, and recognition that their faculty really do bring in external funds for their teaching of house staff (and are thus valuable “taxpayers” in Dr Goldman’s parlance.)
It is amazing that such amounts of money have been flowing for years mostly in secret. The secrecy has fueled incorrect, and in retrospect, bizarre ideas about the funding of medical education, and the value of medical educators to their institutions. This secrecy, in turn, has helped suppress the morale of medical educators, support the control of managers of health care professionals, and distort the flow of money within academic institutions and to compensation for certain favored individuals.

Would our dysfunctional health care system not be better off if we demanded transparency and accountability from its leaders?  In particular, the US government should make payments to hospitals for graduate medical education completely transparent, and develop a system to hold these hospitals accountable for how they spend the money.  Meanwhile, top leaders of hospitals receiving this money should make the amounts transparent, first to the people who are supposed to be doing the education that the money pays for, and to the public at large.  This would allow those running the relevant educational programs to develop reasonable and realistic budgets, to treat their faculty with respect, and to demonstrate what value they provide for the money received.  The ongoing anechoic effect, and related deception and secrecy fostered by leaders in health care are major reasons our health care system is so dysfunctional, that costs are so high, and access and quality so poor.  True health care reform would ensure health care leaders put the mission before their personal enrichment, and act ethically with accountability, transparency, and honesty.

References 1.   DeAngelis CD. Professors not professing. JAMA 2004; 292: 1060-1.  Link here. 2.  Goldman L, Halm EA.  A view from the top: general internal medicine from the perspective of a chair and dean.  SGIM Forum, April, 2007.  Link here. 3.  Pololi L, Ash A, Krupat E.  Faculty Values in the Culture of Academic Medicine: Findings of a National Faculty Survey. Link here. 4.  Liebow M, Jaeger J, Schwartz MD. How does Medicare pay for graduate medical education? SGIM Forum, May, 2012.  Link here.
5. Chaudhry SI, Khanijo S, Halvorsen AJ, McDonald FS,Patel K. Accountability and transparency in graduate medical education expenditures. Am J Med 2012; 125: 517-522. Link here.

–Roy Poses, MD, is a Clinical Associate Professor at Brown University and President of FIRM, the Foundation for Integrity and Responsibility in Medicine, a not-for-profit organization (NGO) designed to raise awareness and to promote accountability, integrity, and transparency in the leadership and governance of health care. He can be reached at roy_poses@brown.edu.   

As outgoing Johns Hopkins Dean Ed Miller and I argued in a letter in this month’s edition of Academic Medicine, formal coursework and knowledge about the health care system should be a requirement for undergraduate students considering careers in medicine. It just makes sense. No one should enter a career path like medicine without at least a basic understanding of the system of care; its financing model; and the social and political issues forces that influence the profession.

But it shouldn’t stop with revised premedical requirements. Medical schools and residencies should be doing more, too. We need to move beyond the status quo—the occasional special lecture, the ill-attended course, and the token boards question—to make policy and management more mainstream. This is not a new argument, but it is a new era. With the implementation of health care reform underway; the transition to electronic models of storing and transmitting health information; and an increasing professional focus on resource utilization and management, clinical training more than ever must take on a population-health orientation—and prepare students for clinical and managerial success. Without a significant change in our profession’s focus, our best efforts to improve care will fall short.

Clinical medicine, policy, and management don’t stand in isolation of each other in the real world. Accordingly, they should not be taught in isolation of each other in medical education. This was a key premise of www.ImproveHealthCare.org, a group Kiran Kakarala and I started in 2002 with the support of the Commonwealth Fund that continues to produce cases studies that bring clinical problem-solving together with policy and managerial questions. Medical schools and residencies must take an approach to integrating the teaching of these issues that allows them to stand together. When it accomplishes this synthesis, students and trainees will cease to see these issues as an after-thought (as they currently do)—and more as a critical part of their training as physicians.

Clinical practice is changing fast—and medical education needs to catch up. Thoughtfully incorporating training in the management science and policy is no longer “a nice to have,” but is instead a must-have.

—Sachin H. Jain, MD, is a physician at the Brigham and Women’s Hospital in Boston, MA. Formerly senior adviser to Donald M. Berwick, Administrator of the Centers for Medicare and Medicaid Services (CMS), Jain was involved in the launch of the Center for Medicare and Medicaid Innovation that was chartered by Section 3021 of the Patient Protection and Affordable Care Act, briefly serving as its first Acting Deputy Director for Policy and Programs. He received his undergraduate degree in government from Harvard College; his medical degree from Harvard Medical School; and his master’s degree in business administration from the Harvard Business School. He can be reached at shjain@gmail.com.

By Kenneth Lin, MD

Yesterday, the family medicine residency program where I serve as a faculty preceptor “went live” with their new electronic health record. They posted a sign at the front desk that read in part: “Pardon Our Progress,” as if we were starting a major construction project — which, in a way, we were. Instead of wading through stacks of unruly paper charts, my colleagues and I logged on to a sleek online portal via laptop computers to review and sign residents’ progress notes. Thanks to months of meticulous preparation and the presence of onsite technical support, the day went relatively smoothly for physicians and patients.

By leaving paper behind, we looked forward to eliminating inconvenience and errors associated with lost charts and illegible or missing documentation. But the most important reason for the switch to an electronic health record was the unspoken presumption that it would allow us to provide better preventive and chronic care for patients. At the end of the afternoon session, I asked the residents how strong the evidence is that practices with electronic health records actually improve their quality of care.

The answer, it turns out, is not very strong at all. In an editorial published in the May 15 issue of American Family Physician, I review the small number of studies that have evaluated the effect of electronic clinical decision support systems (CDSSs) on processes and outcomes of preventive care. Whether the goal was to improve immunization or behavioral counseling rates, electronic health records have had, at best, modest effects:

In summary, the evidence is far from conclusive that EHRs and CDSSs improve preventive care processes and outcomes in primary care settings. The small number of mostly nonrandomized studies makes it hard to determine whether changes in physicians’ behaviors were the result of implementing CDSSs, or if other factors were responsible. Also, the most promising studies to date were performed in large practices of employed physicians, rather than in small physician-owned practices. Finally, all but a few studies measured only guideline adherence, rather than patient-oriented health outcomes. To be worth the investment, EHR-enabled CDSSs must ultimately be shown to not only improve processes of preventive care, but also reduce morbidity and mortality and improve quality of life.

Similarly, a study published in this month’s issue of the Annals of Family Medicine found that in a group of 42 similar primary care practices in the Northeast, those using EHRs were less likely than those without EHRs to meet three diabetes care quality measures (hemoglobin A1c, LDL cholesterol, and blood pressure), and that the gap did not narrow after 3 years.

So what are the chances that our residency’s substantial investment (and the U.S. government’s billions of dollars of incentives for physicians and hospitals to install and demonstrate “meaningful use” of electronic health records) will ultimately pay off for patients? The key to success for integrated health systems such as Kaiser Permanente and the Mayo Clinic has been to use the data from EHRs to manage population health. Rather than the traditional model of treating diabetes one patient at a time, for example, “panel managers” (registered nurses or other non-physician health professionals) can reach out to patients outside of the office visit and make sure that they are receiving recommended care. Who will pay these managers outside of the Kaisers and Mayo Clinics remains a largely unanswered question. The bottom line, though, is that it’s not enough to just collect electronic data. For EHRs to transform primary care, we need to be able to use the data in new and creative ways, improving the health of large groups of patients — and eventually, entire communities — at the same time.

—Kenneth Lin, MD, is a board-certified family physician practicing in the Washington, DC, area. He is Associate Deputy Editor of the journal American Family Physician and teaches family and preventive medicine at the Georgetown University School of Medicine, Uniformed Services University of the Health Sciences, and the Johns Hopkins University Bloomberg School of Public Health. He blogs at http://commonsensemd.blogspot.com.

Suffering from quality campaign fatigue? You can’t be alone. For whatever reason, sweeping, splashy initiatives are common in the quality improvement arena. All have noble intentions, but it can be hard to tell where rhetoric ends and results begin, particularly on a topic like quality improvement, where change literally spreads on a person-to-person level.

The United States Department of Health and Human Services (HHS) has its own entry: the National Quality Strategy. But a new progress report from the department aims to demonstrate how this federal campaign, mandated by the Affordable Care Act and established in 2011, has more teeth than the average iteration.

“There are a plethora of initiatives and measures, but not necessarily a coherent framework,” said Nancy Wilson, M.D., M.P.H., of the Agency for Healthcare Research and Quality (AHRQ), which is helping to lead the strategy. “This will provide that framework, and a focused alignment around measurement and payment reform. It should simplify the life of providers.”

Wilson and others guiding the strategy are looking to state agencies and private payers, as well as fellow federal entities, to develop national consensus around things like clinical measures, data sources, and data collection procedures.

“The strategy itself serves as a framework for quality measurement, measure development, and analysis of where everyone can do more, including across HHS agencies and programs as well as in the private sector,” stated the progress report, released in late April. “In the past year, HHS has also adopted a more transparent process for selecting quality measures for new and existing programs.”

In other words, the federal government is trying to figure out what the health care system should monitor, how providers should monitor it, and how to bake the results into practice and reimbursement. Even more simply put, the end goal is improving the quality of quality improvement.

“What measures do we use for blood pressure control, and can we agree on one? We want to be aligned and parsimonious around our measures,” Wilson said. “We want to keep our compass pointed toward the evidence.”

The strategy also has established a “pre-rulemaking” process, through which HHS will publish a list each December of new measures under consideration.

Of course, any campaign that unspools beneath the auspices of the federal government has one key advantage going for it: payment. According to Wilson, the National Quality Strategy will directly inform payment decisions across the HHS portfolio, including not only Medicare and Medicaid but the Center for Medicare and Medicaid Innovation, the Health Resources and Services Administration, and the “meaningful use” health IT regulations. Indirectly, states and the private sector can pick up the new standards, and several are already doing so, according to the progress report.

“HHS has developed a checklist for use in the review of proposed activities to ensure that all new initiatives align with National Quality Strategy priorities,” the report stated. “The National Quality Strategy has led to collaboration with state partners and has spurred state efforts to redesign their quality improvement efforts.”

Moving forward, the strategy will set targets for success on a greater number of measures and expand into areas like care coordination.

Wilson said the National Quality Strategy will likely not be affected if the health care reform law is overturned by the Supreme Court.

“This is full steam ahead,” she said. “The strategy has been embraced. These are principles that transcend legislation. Hopefully.”

Engaging residents and fellows in quality improvement and patient safety activities has become a goal for all GME programs and a reality for an ever-increasing number. In fact, the 2011 ACGME common program requirements mandate that trainees “systematically analyze practice using QI methods and implement change,” “work in interprofessional teams to enhance patient safety and improve patient care,” and “participate in identifying system errors and implementing potential solutions.” In many instances, however, QI projects are not fully integrated with the institution’s quality and safety goals, and may have minimal impact on patient care or costs.

In order to both increase resident and fellow involvement and to ensure that such efforts are fully aligned with the institution’s efforts, we have instituted at UCSF a quality and safety and cost reduction program that engages trainees in both institution-wide (all-program) and program-specific efforts. Although additional individual projects are also encouraged, our primary focus has been alignment with institutional priorities. Trainee input and leadership, however, remains paramount in helping to identify needed projects.

One way to heighten trainee engagement has been to institute pay-for-performance criteria. Eligible trainees can earn up to $1,200 each for successful completion of the goals. Over the first five years of the program, ten of 15 all-program goals have been met. An average of $800 per trainee has been distributed to almost a thousand trainees each year.

All-program goals focus on major institutional priorities and are aligned with pay-for-performance goals for other medical center staff. For example, increasing patient satisfaction has been a goal for trainees, nurses, and all other staff since the beginning of the program in 2007. Each year the goal is set higher. The goal has been met in all but one year. UCSF now has the highest levels of patient satisfaction in its history.

A second current all-program goal, also aligned with other health professional and staff goals, is improved hand hygiene. Here, too, the goal has been met. UCSF’s hand hygiene compliance is at its highest level (90 percent), a marked improvement from the baseline of several years ago, when it was less than 50 percent.

The third current all-program incentive goal is to decrease the use of unnecessary laboratory tests. Several years ago, we observed that lab utilization per patient admission was higher at UCSF than at peer institutions. Our first goal was to decrease the use of complete blood counts (cbc) and cbc plus differential by 5 percent. This was achieved. In year two, we added fifteen additional common laboratory tests to the goal. Tests were reduced by 8 percent, again meeting the goal. This year (year three), our efforts to decrease these lab tests by an additional 5 percent have not succeeded. The reduction of the two prior years, however, has been maintained. We may be at a new appropriate baseline.

Although the results have been satisfying (and the incentive payments much appreciated by trainees), it is highly likely that the incentive payments themselves were only a partial factor in the program’s success. As noted, many staff worked on these goals in addition to trainees. In fact, especially for patient satisfaction and hand hygiene, extensive efforts were undertaken by all to improve outcomes. Specific programs and an overall change in culture contributed to these successes. But having the trainees involved undoubtedly played a role in the improvements while also meeting trainees’ learning objectives.

As might be expected with such broad goals at a large institution, individual resident engagement was variable. Many reported a commitment to these changes and a few played major leadership roles. Others were aware of the program but felt that the all-program goals were too removed from their daily work. To address these issues, the residents and involved faculty began to conceptualize additional efforts to further engage residents. In 2008, program-specific pay-for-performance goals were instituted.

In this instance, a team of residents, residency program leadership, and physician quality leaders within a clinical department define specific improvement projects. The projects are closer to the work that the residents themselves perform on a daily basis but are still aligned with departmental quality and safety priorities. Each project is defined and submitted to a committee of Medical Center and GME leadership, QI leadership, the Resident and Fellow Council, and program directors and faculty. Proposals are vetted, improved, and resubmitted as needed. During the current academic year, 16 programs are actively working on projects. Workshops are held early in the process to help trainees develop their goals and later in the year to assess trainee progress and make adjustments. Completed work is presented at an end-of-year symposium.

Although still aligned with institutional goals, these department-specific projects reflect a broader range of improvement issues. Examples include more timely communication of biopsy results (Dermatology), decreased room to exam time (Emergency Medicine), increased completion of advance care planning notes (Internal Medicine), further reduction of laboratory test use (Neurological Surgery), increased communication with primary care providers (Pediatrics), and attestation of radiation doses in CT scan reports (Diagnostic Radiology). Here, too, all members of a program receive incentive payments if the project is successful. Last year, three-quarters of the programs achieved their goal.

As with the all-program goals, it is most likely the incentive payments themselves are not the primary factor in the programs’ success. Rather, trainees report that their ability to identify and solve system problems with appropriate mentoring, resources, teamwork, and respect is what makes the program work. For many residents, the program has led to increased competence in performance improvement, system change, measurement, teamwork, and leadership. For some residents, especially the resident champions, this work has motivated them to careers that include continued work in system change and leadership.

From the institution’s point of view, this program has led to cost avoidance and cost savings; enhanced reputation and patient satisfaction; improved outcomes in quality and safety measures; improved collaboration between physicians, nurses, and other medical center staff; and enhancement of the institution’s culture of patient safety and quality improvement. Moreover, the program demonstrates that clinical and educational goals can be fully aligned and integrated, and that learners can be “part of the solution.”

—Robert B. Baron, MD MS, is Professor of Medicine and Associate Dean for Graduate and Continuing Medical Education at the University of California, San Francisco School of Medicine and a Robert G. Petersdorf Scholar-in-Residence at the AAMC. He can be reached at baron@medicine.ucsf.edu

I don’t like to wait; who does? If I have to wait, it helps to know why and how much longer. It helps even more if I have something to do, to read, to listen to, or to watch – praise the smartphone! Disney also knows this: They don’t like hot, sweaty, whining kids any more than parents do. That is why wait times for rides at Disney World and Disneyland are posted; video monitors offer some distraction from the tedium. Even better, you can now get those magical FASTPASS tickets that allow you to return during a certain time window and basically go right into the attraction. You feel more in control because you are off doing something else while actually “waiting” to enter Space Mountain!

I don’t have hard data on this, but I would guess not many folks die while waiting on line at amusement parks, even if at times you contemplated death as the lesser of evils while baking in the hot sun, hungry, tired, and hours away from an adult beverage. However, waiting in an emergency department can be a fatal event. These stories are fortunately infrequent, but probably should be considered “never events.” Even if you do not die while waiting in an ED, your care may be compromised in other ways. You may register, but leave without being seen or treated; that would make you an LWBS or a LWOT statistic. You may simply gasp at the mass of unhappy and unwell humanity overflowing the waiting room, do an about-face and bolt; that would make you a “peek and shriek.” None of this makes for good patient care, risk management, or customer satisfaction.

Does it have to be like that? Staff at the Penn State Hershey Medical Center Emergency Department certainly didn’t think so. Their story is a great example of necessity being the mother of innovation. Facing tremendous growing pains a few years back, handling more than 50,000 visits in a space designed for 30,000, the ED featured long wait times, “door to provider” times of more than 90 minutes, 7-hour average stays, LWOT rates approaching 10 percent, and plummeting patient satisfaction. ED staff knew something creative had to be done, but within significant capital constraints for new construction.

Working with colleagues from the College of Engineering, Chris DeFlitch, MD, vice chair of the ED, and now also CMIO for Penn State, meticulously mapped care processes, workflows, time to task completion, and space utilization. Using Lean concepts, DeFlitch and his team eliminated many of the “non-value-added” steps in an ED visit. One step with no value was waiting for the sake of waiting.

DeFlitch developed the technique known as PDQ, “physician directed queuing.” In this innovative approach, the triage phenomenon simply happens simultaneously with initiation of definitive care, and sometimes serves in and of itself as definitive care. So instead of being sent back into the waiting room, based on nursing assessment, you may  be cared for and discharged. For example, Dr. DeFlitch tells the story of a child presenting with a bead stuck in her nose. Dad had tried to get it out at home without success. Within 9 minutes (yes, NINE minutes) the family presented for care, was seen by the nurse and physician, received instructions, and was discharged.

The technique was piloted in the old physical plant and demonstrated significant systems improvements in LWBS, wait times, door-to-doctor time, and just about every quality measure. Using this process as the driver, DeFlitch worked with construction and design teams to create and build an ED expansion that eliminated the waiting room, and saved Penn State nearly $13 million in capital expenses.

Partnering with the nurse manager and the medical director, Glenn Geeting, MD, the innovation was operationalized and managed in the ED expansion space. “We wanted to prioritize the patient and family-centered care approach, while opening beds for patients who really need them,” says DeFlitch. If you are seriously ill and/or unstable, you get a bed and definitive care begun immediately.

There are still occasional times where rooms are not available, due to admitted patients awaiting placement in the hospital (boarders). To accommodate the wait for an ED bed, DeFlitch created private waiting space internal to the ED. Because care is initiated on arrival, while the patient may be waiting for a traditional ED bed, care has been started.

Intense process and workflow improvement allowed Penn State to accommodate larger volumes with modest reconfiguring of existing space, limited expansion of new space, and minimal capital outlay. Best of all, provider and patient satisfaction has improved, ranking near or at the top of UHC rankings: door-to-provider time below 20 minutes and total dwell time dramatically reduced. LWOTs are as rare (0.4 percent) as black swans, and the waiting room is gone. Really! It’s not there anymore. All you will find in front of the arrival area are a couple of chairs in the event someone needs to sit down before they faint when they find out there is no waiting room!

This is a great example of how academic medical centers can harness the interdisciplinary, intellectual horsepower of their universities to direct focus on solving health system problems. Penn State has created the Center for Integrated Healthcare Delivery Systems (CIHDS) to develop and support this kind of interdisciplinary thinking being done at Penn State and elsewhere. It can and should be done everywhere.

—Michael Weitekamp, MD, MHA, FACP is a Professor of Medicine at Penn State College of Medicine and a Robert G. Petersdorf Scholar at the Association of American Medical Colleges. He can be reached at mweitekamp@aamc.org.

By Karen Sibert, MD

One morning recently, I found another physician standing morosely at one of the mobile computer terminals we refer to as “cows”—computers on wheels—that are everywhere now in our hospital. I asked what was the matter. “Oh nothing, really,” she said. “It’s just that I don’t feel I know the patients as well as I used to.”

I knew exactly what she meant. Things are different now that we have the EMR, the electronic medical record. After two months of use, we’ve learned to our sorrow that these records don’t tell us stories that make cognitive sense. They offer information in endless lists.

Before the written word, people told stories. In every culture, around hearths and on journeys, they remembered and retold tales of great deeds, romance, and tragedy. When we were medical students, we learned to present each case on rounds by telling the patient’s story. The story had well-defined elements: the current complaint, the background of genetics or misfortune that led up to the present, the investigation that might clinch the diagnosis, and the plan of action.

The best stories almost told themselves. The business executive fresh from a transatlantic flight presented with shortness of breath; VQ scan revealed a pulmonary embolism. The young woman with Marfan’s syndrome began exercising one morning and developed severe chest pain radiating to her back; the echo demonstrated aortic dissection.

Now, however, we have lists.

One list will give us the medical history. In no particular order of priority, it includes one-word problems such as osteoarthritis or hypertension that have nothing to do with the patient’s current admission for acute pancreatitis. The relevant history of alcohol abuse may be found elsewhere, in the list under “social history.” Our “social history” includes a field that will tell you whether or not the patient chews tobacco, which is so seldom helpful in southern California. The complaint of abdominal pain won’t be found anywhere near the list of laboratory values with the important amylase and lipase levels.

If you’re a consultant trying to make sense of the patient’s case, you can find yourself frustrated and stymied at the difficulty of getting the big picture. If you’re lucky, you can find a human who knows something about the patient, and get him or her to tell you the story. You can bet that this won’t be the resident, who has just come on the service, didn’t admit the patient, won’t be following the patient, and will have to lie down for a nap soon. But with perseverance you may find an attending physician who has no duty hour restrictions and actually knows what’s going on with the patient.

If finding a human fails, your second hope is to find a narrative note by a physician who is in the old-school habit of dictating an organized history and physical. This is the pot of gold in the EMR, but you may have to sift through pages of notes on the computer before you find one. Sometimes, just for fun, I print it out so I can refer back to it without logging on to anything.

The use of all the “smart fields” in the EMR looks appealing at first until you realize that they propagate themselves endlessly, like tribbles. The same “past medical history” will appear as an identical list in note after note, because it’s so easy to type “.pmh” instead of summarizing the patient’s problems as a narrative. If an error of any kind is made, it will continue until someone notices and takes the trouble to delete it. If “Lasix” instead of “latex” is entered as an allergy, it may be listed that way indefinitely. You’re much more likely to click on the wrong line of a list than you are to write down the wrong information in a handwritten note.

With the billions of dollars that are being spent on EMRs, and the Obama administration’s keen interest in their implementation, no one wants to hear about the problems they cause. But the truth is that it’s much harder for physicians and everyone else in the hospital to learn and remember what they need to know about their patients from reading electronic records. Human beings don’t learn best by memorizing disconnected lists. From fairy tales to patients’ histories, we’re hard-wired to remember stories.

—Karen Sibert, MD, is an anesthesiologist in Los Angeles. She blogs at A Penned Point.