June 10, 2011 – Information technology is emerging that may change the nature and scope of the hospital quality review process, leading to lower health care costs and better quality care. A pathologist in the United States, David Jadwin, has created a quality review platform that gives physicians unbiased and anonymous feedback based on independently reviewed medical charts. The platform makes possible the extraction of pertinent clinical information from any medical record without requiring an electronic medical record.
The data from medical charts is abstracted without any work required by hospital staff. Using information technology and working with paper or electronic medical charts, key documents are uploaded via the internet to the information platform. To ensure patient confidentiality, each document is redacted to completely de-identify all proper names, including not only the patient’s confidential information, but the name of the hospital, the names of physicians and even the geographic location.
This external review process employs a home-based labor force to process chart documents and consequently creates jobs for people who might otherwise not have access to employment. The business concept behind external review is to use lower level staff to assemble data, so that physician reviewers or other healthcare workers are able to review charts very quickly, often in less than one minute per chart.
Since chart documents are fully redacted, those viewing chart documents have no idea about the identity of the patient, the hospital or the physicians involved with care. Information is assembled in chronologic order and linked to source chart documents to create a compelling assessment of whether patient care and treatment is appropriate or could be improved.
The Evidence
The power of external review to impact healthcare quality is revealed by its application to reduce unnecessary blood transfusions. Thirty to fifty percent of blood transfusions do not provide benefit to the patient and have been shown to cause adverse patient events and increase length of hospital stay. Critically-ill patients treated within intensive care units that were placed on restrictive blood transfusion protocols were shown to have shorter length of stay and no difference in outcome when compared to patients who received liberal blood transfusions.
Blood transfusions have been linked with higher rates of myocardial infarct and death. Patients undergoing bloodless coronary bypass procedures have better outcomes that bypass procedures. Women with ovarian cancer have shorter cancer relapse times if they receive blood and women with ovarian cancer who do not receive blood may possibly survive longer.
On the other hand, Jehovah’s Witness patients who refuse blood transfusion often progress just as well, if not better, than patients who consent to have blood transfusions. All of these considerations have led to a surge in “bloodless” medicine and surgery centers that provide therapy to patients who would otherwise receive blood transfusions.
Experience with external review of hospital charts has led to an immediate fifteen percent reduction in blood use just through physician awareness that all blood transfusions will be evaluated by an external review process. This phenomenon is known as the “Hawthorne Effect”, a form of reactivity whereby subjects improve or modify aspects of their behavior simply in response to the fact that they are being studied.
Dr. Jadwin’s work shows that External review not only produces an immediate improvement in physician behavior, but also changes physician behavior by demonstrating errors they make whenever treating patients. It is often said that ninety percent of physician practice is performed on the basis of rote memory and the last bad mistake. As horrible as this may sound, it is true that physicians are savvy enough to avoid repetitive errors.
External review, therefore, is perhaps the most effective process to rapidly improve physician practice because it demonstrates to physicians how to provide better patient care through critique of their actual patient case management and clearly demonstrates opportunities for improvement. It is powerful precisely because it doesn’t tell physicians how to practice, but shows them ways that better care might have been provided.
In the United States, $800 billion dollars is spent annually for medically unnecessary healthcare. It is possible that the Canadian health expenditures for unnecessary care occur at a proportional rate. This level of inefficiency cannot be effectively corrected by individual hospitals attempting to provide incrementally better care.
Real improvement in healthcare systems requires rethinking old practices, and Doctor Jadwin’s external review platform could be a part of the solution to improving quality of care while reducing unnecessary costs.
Keywords: healthcare, treatment, costs, patient
