The AMA: A commitment to quality, safety, and science
March 5, 2008
Florida Health Care Coalition
15th Annual National Conference
Orange County Convention Center
Cecil B. Wilson, MD
Immediate Past Chair
Board of Trustees
American Medical Association
It is a pleasure to be here representing the American Medical Association -and to be able to drive in from my office in Winter Park instead of heading to the Orlando International Airport for a trip across the country.
Thank you for this opportunity to talk about where the AMA stands on the issues surrounding the title of this conference - the Healthcare Revolution: Using Transparency as the building block for Benefit Design and Quality Improvement.
My remarks will focus on some of what I would call the ingredients or facilitators of transparency that are currently being considered as a part of the health care environment of change in this country.
I will highlight performance measures, health information technology, quality, pay for performance, patient safety and so-called I'm sorry laws.
To begin however, part of the story I would like to share with you is to report that the AMA has always had a focus on quality, patient safety, standards, ethics.
Since it's founding in 1847, some 160 years ago, the AMA and its member physicians have been committed to quality improvement and scientific innovation.
The first AMA meeting agenda included the formation of a committee on medical education that set the first-ever standards for teaching medicine in the United States.
That first year, a code of medical ethics was also established. It has undergone constant updating and revision and today stands as the most respected in the world.
Early on, the AMA also focused on educating the public about the dangers of quack remedies and nostrums, sought regulations regarding quarantine of patients with infectious diseases, and fought for general public sanitation.
In 1883 the Journal of the American Medical Association was founded to publish and widely disseminate peer reviewed scientific articles. It is now published in more languages than any other such journal.
Medical education throughout the country continued to be a major concern of the AMA, and in the early 1900's its Council on Medical Education inspected and rated 160 American medical schools.
This led directly to the Flexner report, which revolutionized medical education in this country.
In 1942 the Association of American Medical Colleges, and the American Medical Association formed the Liaison Committee on Medical Education (LCME), which accredits medical schools.
Currently the LCME accredits 125 programs leading to the MD degree in the United States.
One of the next on the list for accreditation will be the Burnett College of Biomedical Sciences, which, when finished in 2010, will form the cornerstone of the medical college underway at the University of Central Florida here in Orlando.
It got its preliminary accreditation last month and can now start recruiting students.
The AMA's commitment to quality goes beyond education. We're also advancing the science and practice of medicine.
And that takes us to the story of what is happening now
Physician Consortium for Performance Improvement
Since 2000, the AMA-convened Physician Consortium for Performance Improvement, which includes more than 100 state and specialty medical societies, has developed 213 evidence-based, physician-level performance measures.
These provide physicians up to date information about diagnosing and treating illness.
The AMA's performance measures, such as those for coronary artery disease and hypertension are being used in health plan and Medicare demonstration projects, and makeup 80 percent of the measures to be used in Medicare's new voluntary physician reporting program.
In addition, the Consortium is working with health information technology vendors to incorporate the performance measures in electronic medical records programs, making them readily available to physicians as they are seeing patients.
In 2006, with support from the AMA and other groups, "The National Patient Safety and Quality Improvement Act" was passed. This legislation enables all health professionals to report mistakes or near-errors confidentially and voluntarily.
Regulations for implementation of the act were just published and the AMA will be working to assure success. It took two years.
Now, patient safety organizations across the nation will be able to collect comprehensive data about problematic incidents.
Using this data, they will help to create new safety systems to prevent such incidents from happening again. This model has been very successful in the aviation industry, and it should work for medicine, too.
But we are not just waiting for future data. The AMA is also putting existing knowledge to work.
One of our efforts is our partnership with the Institute for Health Care Improvement (IHI) headed by Dr. Donald Berwick.
The IHI has promoted the idea that six interventions, done routinely and completely in the hospital setting, could save as many as 100,000 lives in a single year. These interventions include:
- Deploy Rapid Response Team at the first sign of patient decline;
- Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction to prevent deaths from heart attack;
- Prevent Adverse Drug Events by implementing medication reconciliation;
- Prevent Surgical Site Infection by reliably delivering the correct preoperative care;
- And Prevent Central Line Infections and Ventilator-Associated Pneumonia by implementing a series of interdependent, science-based steps for each.
Some or all of these interventions have been adopted by 3000 hospitals across the United States.
The AMA helped by reaching out to the physician population through our "Making Strides in Safety" program, and by encouraging the participation of hospital medical staff.
These interventions truly work. For example, 30 hospitals consistently applied the protocol for ventilator-related pneumonia - and saw rates of this pneumonia drop to zero for a year, in some cases longer.
The overall impact of the campaign has likewise been powerful. It's been estimated that this campaign has saved more than 120 thousand lives, simply because participating hospitals and medical staffs routinely put interventions into place.
Meanwhile, the AMA is also working in the area of Health Information Technology and how to make these advances work for physicians and patients.
We share the widespread optimism over the promise that health IT holds for transforming patient care if properly developed and carefully integrated into the existing health care delivery system.
We're encouraged that Congress recognizes the importance of moving toward an interoperable health information technology infrastructure and understands the crucial role the federal government will play in its viability.
Health IT has the potential to raise the overall quality and safety of patient care.
It could revolutionize the practice of medicine and the delivery of health care by putting real-time, clinically relevant patient information and up-to-date clinical decision support tools in practitioners' hands at the point of care — at the moment of care.
Similarly, it holds promise in the areas of preventive care, chronic disease management, biosurveillance, public health monitoring, and could produce increased efficiencies in electronic communication.
The AMA supports the continued development, adoption, and implementation of national, interoperable Health IT standards, including issuance of electronic prescribing standards, through collaboration among and between public and private stakeholders.
And as you might imagine, the AMA has some strong ideas on how these technological advances should be put to work.
Physicians are mainly concerned with two things in this area related to the impact on patients: privacy and cost.
Privacy of electronic health records is self-explanatory. Physicians and their patients should have control over patient health records.
This caution is especially important with Microsoft, Google and Revolution Health all now competing to form online repositories for personal health records.
Without complete assurance of privacy and security, patients will be reluctant to tell their physicians how they're hurting. The trust that is so important to the effectiveness of the patient physician relationship will be lost.
Cost, of course, is another matter. Some large health systems and hospitals can afford Electronic Medical Records, but many small practices can't.
And most of the care in this country is provided by small practices.
Fifty-two percent of physician offices are groups of three or less and 75 percent of care is provided by groups of eight or less. Installation costs run $30,000 to $40,000 per physician plus $4-5,000 in annual maintenance.
In addition, the fact is, only 11 percent of the return on health information technology investment goes back to the provider. The other 89 percent goes to third-party payers, the government, insurers and others.
There are similar challenges involved with a special subset of health information technology, electronic-prescribing, so-called e-prescribing widely thought to have significant benefits in the area of patient safety.
It has something, but not everything, to do with getting around physicians penmanship.
Physicians on average write 30 to 40 new prescriptions a day and about 100 refills.
And despite popular perception, most pharmacies and insurers are not ready for e-prescribing.
Only 4 percent of pharmacies are connected electronically to physicians' offices - and only another 12 percent even have a system to receive faxed prescriptions.
So we need to make sure an infrastructure is put in place.
We need to ask also, who will pay for these technological advances related in this case to electronic technology?
The answer is, simply — everyone. Right now, the AMA is working alongside groups like the American Academy of Family Physicians to encourage Congress to pass legislation that allows physicians, industry leaders, insurers and others to develop collaborative financing.
Some of us are lucky to work in health care communities that have a head start on getting wired. But many of my colleagues around the country aren't so lucky. They're just trying to make ends meet, and health information technology seems like an unattainable luxury.
So, the AMA is asking that Congress look at ways to assist physicians, such as grants, loans, tax credits, and other economic incentives.
One very specific way they can help is through Medicare physician payment reform.
Medicare payment cuts of 15 percent are scheduled to go into place over the next 18 months.
A recent AMA survey shows that half of America's physicians say if that happens, they'll have to defer purchase of health IT and other technologies. That's a problem.
More importantly, nearly half of physicians also say they'll be forced to reduce or stop accepting new Medicare patients, and since Medicare sets the bar for payments in the private sector, many health plans could also decrease their reimbursements.
These draconian cuts are not sustainable by America's physicians, most of whom are trying their best to run their own practices that are actually small business.
Pay for performance
Another increasingly hot issue relating to medical quality is a growing awareness and implementation of pay for performance programs.
Pay for performance programs are incentive programs that provide monetary bonuses to participating physicians who achieve quality and/or efficiency benchmarks.
The number of these programs across the country has grown from 39 in 2003 to 148 in 2007.
Half of those that have been evaluated have reported improvements in clinical performance and one-third demonstrated cost savings.
The AMA believes that when pay-for-performance programs focus on quality, they may have a positive impact on the quality of patients' care.
However, some so-called pay-for-performance programs give lip service to quality, while focusing almost entirely on reducing costs for insurers.
This type of program harms the patient-physician relationship by putting barriers between patients and their physicians.
Controlling growth in health care costs is an important goal, but it must not be done at the expense of quality care for patients.
AMA principles for P4P
The AMA Principles on pay-for performance can help ensure that these programs are patient-centered and appropriately applied.
We believe fair and ethical pay-for performance programs should:
- Ensure quality of care
- Foster the relationship between patient and physician
- Offer voluntary physician participation
- Use accurate data and fair reporting
- Provide fair and equitable program incentives
I'm sorry laws
When errors do occur, physicians have been compelled to remain silent lest self-incrimination occur and words uttered in apology are used against them in court as admissions of guilt.
Now, more than half the states in the US have enacted "I'm Sorry" laws to protect physicians and others who express sympathy to a patient for an unanticipated outcome.
For instance, in Florida, the statute requires that "an appropriately trained person designated by [the hospital] shall inform each patient…in person about adverse incidents that result in serious harm to the patient."
Thus, if a surgeon practicing in Florida has an incident during surgery that results in an adverse outcome, he or she is obligated by law to inform the patient about the incident, and the admission cannot be used in court to prove liability. [Virtual Mentor. April 2007, Volume 9, Number 4: 300-304.]
Opening up communication in this way enhances trust levels, candor and cooperation between patient and physician. Recognizing errors also provides the opportunity to investigate and learn root causes and institute systems to prevent future errors.
Transparency - to be transparent - so sheer as to permit the passage of light through; also and more to the point of this discussion - easily seen through, recognized, or detected; easily understood, manifest, obvious.
Historically there was a paternalistic culture surrounding health care that assumed the provider knew best and could decide for the patient; and that the patient could not adequately understand and did not need to know everything about his or her health care.
Hopefully that paternalistic culture is gone or at least near an overdue demise.
I believe we know much better now the importance of patient participation in and control of their health care.
I believe we know better now that patient participation is not only a right, but that an informed patient is an important ingredient in successful care.
The challenges for all of us as we seek to inform the patient by making health care more transparent are to assure that it is, as the definition states, easily understood, manifest, obvious and presenting an accurate picture.
And it is in those challenges that the hard work must be done; and it is in those challenges if we are not successful lies the risk of harm.
And it is based on awareness of risks in that area that I have shared with you some of the AMA's concerns.
We have a saying in Medicine, First do no harm.
In that vein I would suggest that the imperative for change must include an imperative for making things not worse, but better.
For most us, what comes next is still much of a mystery. As everyone's favorite philosopher Yogi Berra said, "I hate to make predictions. Especially about the future." So what are some of the questions?
How will technology affect how medicine is practiced 10, 20, 30 years from now?
Some entrepreneurs might someday install video medical kiosks at your local mall - or within your local pharmacy.
Maybe even entire hospitals will be built using only video screens, robots, microphones, and slots to first insert blood and urine samples, and later your credit card.
There are likely as many possible uses as there are creative minds - and I don't doubt for a second that those minds are already at work.
But as you think of "what's next," let me raise a few issues that bear consideration - and that the AMA is closely watching.
These pressures and market forces are strong and compelling, and more than just another passing blip on the health care radar screen. They have implications across a broad array of very important concerns.
Continuity of care and quality of care must be preserved.
Patient confidentiality and proper supervision of care by physicians must be assured.
The impact of how insurance handles these new delivery approaches is a critical factor - who is paid - how much - and for what?
How will telemedicine, home monitoring and receiving care at multiple sites affect the ability to track patients' records? An electronic medical record is one answer to that, but are there others?
Do we really want to replace the human interaction of a patient-physician relationship with a two-dimensional screen? Hopefully that will not be the choice. Hopefully we can preserve the patient-physician relationship while enjoying the benefits of modern information technology.
Will electronic records necessarily solve continuity of care issues if patients receive care at multiple sites? Not if electronic medical records are not interoperable.
We describe the Internet as an example of a disruptive technology, something changing in a major way the way our lives are conducted and in this case medical care provided.
On one hand, it is making information available with a speed and ease barely imaginable only a decade or two ago.
But it is also opening up equally unprecedented opportunities to not only capture and use to help, but also to have the potential to exploit information about groups and individuals, including patients and their doctors.
We at the AMA are committed to preserving the safeguards related to assuring confidentiality of patients' health care while taking advantage of new ways to provide transparency that encourages high quality care that is compassionate and efficient.