It’s Greek to them
Doctor-patient miscommunications account for preventable repeat visits to the ED, panel says
Patient-care advocates are hoping Congress acts soon on a bill that would provide federal funding for programs to improve patient understanding of simple medical directions. The aim is to reduce the number of repeat hospital ED visits and admissions resulting from medical complications due to misunderstandings between patients and their providers.
The poor level of understanding among a growing number of patients in the U.S. has become a major patient safety concern, says Ruth Parker, MD, a professor of medicine at Emory University in Atlanta.
“What’s become increasingly apparent is that an everyday task [such as reading a prescription drug label] is not as simple as it seems,” for thousands of Americans, said Parker, a researcher with the Institute of Medicine in Washington, DC.
Problems associated with poor health literacy account for a preventable number of increased ED visits and hospitalizations each year, according to the IOM. Obvious language differences are only part of it, Parkers says. The complexity of today’s medical care and the jargon associated with it has driven a wedge between what physicians prescribe and what patients understand.
The National Health Literacy Act of 2007 is currently awaiting Senate action. If passed, the law would help fund patient and provider education programs aimed at bridging the communications gap.
Under the law, cities and states would set up health literacy resource centers possibly through hospital councils and medical associations that would coordinate public-private efforts to provide health literacy education services. It would also fund a Health Literacy Implementation Center within the current federal Agency for Health Care Research and Quality to support these local efforts. The national center would act like a national resource center that would collect research, sponsor demonstration projects, and develop best practices for the local sites.
Parker is also working with the American Association of Medical Colleges to develop health literacy courses for future physicians.
Is there an on-call specialist in the house?
EDs are struggling to reverse a decline in clinicians willing to work on call. What are they doing that may work?
If your hospital has difficulty securing coverage from on-call specialists, help may be on the way. For more than a decade now, EDs around the country have been facing a near-crisis in getting anesthesiologists, neurosurgeons, and other specialists to come in when needed. One possible solution has been for hospitals and medical groups to hire their own specialists, according to one study.
The problem of retaining on-call specialists isn’t just occurring at night or on weekends but at all hours, according to a report from the Center for Studying Health System Change (HSC), a Washington, DC research group, which conducted the study.
In recent years, hospitals have been trying a variety of tactics to attract and retain specialists, even resorting to gentle threats. Some have begun to enforce its bylaws, reminding specialists that they may lose their admitting privileges if they don’t comply. Others are providing extra payments for on-call coverage and for treating the uninsured.
Such inducements, however, have had mixed results, according to Ann S. O’ Malley, MD, the report’s co-author. “Nothing hospitals have tried has been universally successful. They’re really stop-gap measures,” O’Malley said.
However, an increasing number of providers are resorting to hiring their own specialists. “Hospitals are moving beyond contractual or stipend arrangements toward a direct employment model,” O’Malley said. Providers are doing so fully aware that they’re walking a fine line between ensuring on-call coverage and alienating other community-based specialists with their patient referrals, O’ Malley stated.
In Phoenix, the Arizona Hospital and Healthcare Association says at least one of its members has hired specialists but did not reveal the hospital or give specifics on its success. HSC was tight-lipped about revealing its study participants as part of a confidentiality agreement.
Insurers are also weighing in. An unnamed Little Rock, Arkansas, health plan, according to HSC, requires that physicians provide on-call coverage if they want to contract with the payer. In other cases, hospitals are stipulating on-call coverage in their own contracts with group practices. The HSC study suggested that the health plan arrangement is a novel, new industry approach to the problem. Arkansas’s largest insurer is Arkansas Blue Cross and Blue Shield based in Little Rock.
The report stopped short of evaluating how well these measures are working. However, O’Malley said the success rate of most efforts has been tied to individual market conditions. “To date these measures have depended on the size of the health care market, the number of patients seen in individual emergency rooms, the overall physician supply, and other factors,” O’Malley said. “Nothing has worked particularly well.” So far, employing specialists outright has proven the most effective, O’Malley added.
But in recent years the problem has worsened and isn’t expected to improve much. “The traditional role of physicians taking emergency calls as part of their obligation for hospital admitting privileges is unraveling,” the study report stated. Inadequate payments for emergency care, especially from the uninsured, a shift away from ED care to clinics and other, less overburdened treatment settings, and increased fears of medical liability associated with EM do not help.
The HSC study tracked conditions in 12 communities, including Boston, Cleveland, and Miami.
Fighting city hall just got easier
AMA adopts policy points aimed at improving physician-hospital relations
Hospital-based physicians have finally picked up an important ally in their disagreements with hospital boards over policy-making matters that directly affect how they treat their patients. After years of little or no action, the American Medical Association has stepped in to try to ease the tension.
The Chicago-based AMA has implemented a set of guiding principals for member physicians to use in their dispute resolution proceedings with hospital boards over clinical and administrative matters.
At the center has been a conflict over what physicians feel they need and what hospital boards say they want on everything from patient safety practices to financial decision-making. Physicians for the most part have been on the losing end of these power struggles because their voices have largely gone unheard, advocates say. The 12 principles codified by the AMA at its November House of Delegates meeting provides some badly needed direction and guidance for docs, according to emergency physician Brian Johnston, MD, an AMA delegate from California. In effect, the principles give physicians a stronger voice in negotiating hospital rules, including those that affect patient care.
They include giving physicians primary responsibility in credentialing, privileging and overseeing clinical quality and patient safety, and giving docs a greater say in developing hospital rules and bylaws. Principle Nine, for example, provides that physicians “elect member representation to attend, speak, and vote at governing board meetings.” Number Six directs docs to “have inherent rights of self-governance, such as shaping bylaws, and disciplinary actions.”
Surprisingly, until now the AMA has had no policy regarding physician-hospital relations.
“This is a vital struggle,” Johnston recently told a reporter. “If physicians lose self-governance, we won’t be able to practice medicine to the best of our ability,” he stated.
The 12 principles have no binding effect on hospital boards. They’re designed primarily to expedite discussions, proponents say. But ultimately, they’ll “signal to the health care community that there is an urgent need to find and build on common ground,” the AMA stated in adopting the principles. Physicians are likely to watch what effect their actions have on future hospital board decision-making.