Pay For Performance, Patient Outcomes, and the Rock of Gilbraltar

Posted on April 30, 2009 I Written By

Quickly, now — which is easier to support?  I’ll give you a hint — most times, my little 5’0 personage would be choosing hoisting that rock on my shoulders.  Honestly, though, I’ll say that famous answer in healthcare, that it depends on the clinic.

Many years ago, when I was working for a very large multi-site cancer center,  I was called into a meeting with all the bigwigs.  You know, VP’s and such.  It was my first time, so be gentle.  I really didn’t understand why I was being asked, and the meeting invite was notoriously vague.  I was ushered into a very posh board room that I didn’t even know that we had (complete with video conferencing), at a round table with approximately 27 other people who were most definitely paid a lot more than I was (and had a bit better fashion sense, compared to my frazzled, just out of the data center look).  One of the VP’s announced that he was planning to look for a cancer-specific EHR/EMR that would encompass both radiation oncology and medical oncology, and interface with the main EHR that the hospital overall was going to implement.   He wanted to use the data that we gleaned from such a system to support one of the largest research studies done in a particular type of cancer therapy, in a prepatory round for pay for performance.  Then, he informed us that one of our vendors had said they were able to fill this need. 

The problem was, I knew that they couldn’t.  And I’m one of those people who doesn’t know, apparently, how to keep her mouth shut.  My immediate response was “They’re lying.”

“Oh, but they promised me.”

“I understand that, sir.  But they ARE lying.”

 I ended up with another four hours cut out another one of my days to be one of the folks who had to sit in on the demo.  Even worse “SM” pulled me aside and told me I had to run it, and I had to prove or disprove whether or not this integration was possible.   It was a grueling four hour ordeal for both me and the dog and pony show man, during which I did indeed uncover that they weren’t an integrated solution.   When I did, someone actually got up and ran to tell SM.

Moments like those make you wonder.

Even after we reported back to SM that we absolutely would not be able to support this research with a system (this vendor, we knew, was the closest), it was decided they were going to go forward.  Somewhere in all of this, I was assigned the entire deal — from the construction of the database to hold it (and the ability for folks working remotely to log into it to use it), to the design of the forms to gather the data (ranged from size of tumor to dosimetry data to whether or not they could still spit or eat steak), to the management of the bodies in motion.

Because I started as a database guru, I was given the task of cleaning up the treatment system data for radiation oncology, and bumping it up next to the chemo information we gleaned from registrars examining paper charts, and minimal amounts of information regarding the medical oncology from the paper chart and billing data.   Two of our radiation sites were ‘islands’, and yet another one at the time didn’t even have a robust record and verify system at the time.  This made for an extensive process.  Since part of the research was being administered as a telephone questionnaire, I also had to come up with the best call lists as I could.

I made sure to filter all the dead patients I possibly could out of the data set — not only did I use the SSI Death Index (doesn’t include goverment workers or teachers, and several other occupations), but I also used all the systems we had for the entire health system (I was a cool kid with the access).  I did everything I could, but in the end all of that was beaten when I sent the list to the site managers, who had their secretaries note additional deaths they had recorded from the newspaper.  You see, that was actually our best way of determining if a patient was, in their terminology “CTB.”  Which means Cease to Breathe.  I requested in earnest that if I died, that I was called dead.

In the end, they got their data — and we went through this painful process two more times for two other studies of the same therapy across differing diagnoses.  But one of the hard lessons came when I was cleaning up some of the data (I was one of the people who helped to type it in, since some of the clinics didn’t even have remote access due to affiliation issues).

The question was regarding whether or not the patient could chew their food.  You see, shoot enough radiation at someone’s head (it was a head and neck study), and their salivary glands won’t work. 

Unfortunately, the doctor had not properly noted the patient’s diagnosis ANYWHERE – it was billed wrong and clinically noted wrong.  We knew it was somewhere in the head, but it was a very non-specific head and neck ICD-9 (lemme show some ICD-10 love).  So, when the nurse called and asked the question, the patient’s wife had answered:

“You cut my husband’s tongue out.”

Lesson:  Every physician must be a champion of health data in order for HIT to truly succeed in any realm.