Learning to say “I’m sorry” is one of the first lessons of childhood. An apology not only opens up the opportunity to mend relational breakdowns, it has the potential to release amazing healing energies. In the context of medical errors, however, apologies have been few and far between. The reason lies in the fundamental change that happens when an unanticipated medical outcome occurs (ie, the parties leave the medical environment and enter the legal environment).

Attorneys, insurance companies, and hospital administrators advise and sometimes even require that health care providers (eg, physicians, nurses, other clinicians) avoid apologizing for medical mishaps, and there is good legal reason for this decision. An apology is considered an “admission against interest” and, as such, is admissible in a court proceeding as evidence of acknowledgment of fault. The adversarial system in which patients and providers find themselves sets up a wrenching scenario. Practitioners are advised to keep their mouths shut for fear of providing damning evidence, and patients’ righteous anger builds against a wall of denial and silence. The results can be explosive. In response to growing evidence of the salutary effects of full disclosure of medical errors, however, the concept of acknowledging responsibility and apologizing for mistakes is gaining momentum.

THE EFFECT AND POWER OF APOLOGY

Silence and denial after a medical error can lead to bad results, including

* anger and hurt about the unanticipated outcome;

* a sense of betrayal of trust, relational disconnect, or destruction; and

* sentiments ranging from frustration to fury regarding the perceived thwarting of the patient’s natural desire for information after an event.

Conversely, the interjection of an apology into this situation yields several ameliorative results. An apology subtracts the insult from the injury. Furthermore, an apology

* restores the aggrieved person’s respect and dignity;

* decreases anger;

* helps prevent antagonistic behavior;

* promotes natural, open, and direct dialogue;

* furthers reconciliation; and

* assures the injured party that both victim and offender share the same moral values in a world with common ethical standards.

Information, candor, and expression of accountability are what many injured patients and their family members seek. These values are part of what an apology provides.

Apologies have great power in the legal arena as well. “Nothing is more effective in reducing liability than an authentically offered apology.” Studies have shown that apologies encourage settlement of grievances and avoid litigation. A British study found that 37% of patients and family members bringing suit may not have done so had there been a full explanation and an apology, factors more significant than monetary compensation. A US survey found that in situations when moderate medical errors occurred, only 17% of patients would sue if the physician informed the patient of the error. If the physician did not inform them, however, 29% of patients would sue if they later learned of the error. One commentator asserts that in the medical malpractice context, 30% of all plaintiffs claim they would not have sued if only there had been an apology.

In a study involving the Veterans Administration Hospital in Lexington, Ky, administrators adopted a disclosure policy that required

* identifying an instance of accident, possible negligence, or malpractice;

* notifying the patient that there was a “problem with care” they received;

* holding a face-to-face meeting to disclose all aspects of the event; and

* offering continuing assistance to the patient in obtaining compensation.

At the meeting with the patient, the hospital chief of staff is directed to express regret, detail corrective action taken to prevent similar occurrences, and offer restitution. The program has reaped significant rewards. Lexington’s average malpractice award dropped from $98,150 to $15,622, less than 10% of malpractice claims were filed in court, and most of these were dismissed before trial.

The University of Michigan Health System adopted a similar program and was able to reduce its legal budget from $3 million to $1 million in 18 months. Disclosure, candor, and apology combine to mitigate the costs of medical mistakes.

Two TYPES OF APOLOGY

An apology can have several definitions and take several forms. Generally, an apology refers to remarks made after an injury occurs, whether it is intentional or unintentional. In this usage, an apology is defined as

an admission of error or
discourtesy accompanied
by an expression of regret
… an expression of regret
for a mistake or wrong
with implied admission of
guilt or fault and with or
without reference to mitigating
or extenuating
circumstances….

Apologies fall into two discrete categories: expressions of sympathy or benevolence (eg, I’m sorry you are hurt) and expressions of accountability and remorse (eg, I’m sorry I hurt you). The benevolent or sympathetic apology expresses regret regarding the damage, injury, or pain but stops short of acknowledging responsibility for the event. It is empathetic and compassionate but ambiguous. The accountability apology (ie, authentic apology) is a personal acknowledgement of responsibility for a specific mistake or grievance, along with an expression of remorse appropriately tendered to the aggrieved party. The difference between the two types of apologies has engendered debate among legal scholars, medical professionals, and commentators.

The American Health Information Management Association (AHIMA) recently released its electronic health record (EHR) standards to the general healthcare industry. Initially released as a member benefit last fall, the standards offer guidance for areas that play an integral role in the transition from paper-based to EHRs.

Information in the HotList is based on survey responses collected from companies with products in the category covered. The HotList is not intended to reflect the quality of products or services, nor is it intended to be an inclusive list of the field.

Additional information about the products described in the HotList can be obtained in two ways:

Product Link. Go online to www.healthmgttech.com and click on “Product Link” to send your request for info through online.

RSLeads. Use the “RSLeads” URL for the companies that interest you to do your own preliminary research online. Most often, the RSLeads URL will take you beyond a company’s home page more directly to the product or service described in the HotList.

Because the HotList is an editorial feature presented as a service to HMT readers, all submissions for the HotList and all entries in the printed HotList are reviewed and decided upon by HMT editors.

2004 HotList Topics

* April, managed care systems

* May, EMRs/CPRs

* June–2004 Resource Guide (no HotList)

* July, wireless

* August, financial info systems

* September, claims & coding systems

* October, practice management

* November, PACS/imaging/ radiology

* December, security

A number of healthcare advocacy, provider and consumer groups fear changes to new medical privacy rules could give a “green light” to banks and other financial institutions to access sensitive, personal medical information.

“Financial institutions have expressed strong interest in data mining information they obtain through transactions and in using this information for marketing to their existing customers, finding new customers and evaluating credit risks,” the Health Privacy Project, the Electronic Privacy Information Center and 28 other groups said in a letter to HHS Secretary Tommy Thompson. The groups are protesting lobbying by some in the financial services industry to roll back “critical consumer protection.”

Current HIPAA privacy regulations prohibit financial institutions from accessing health information for data mining purposes, according to the Health Privacy Project.

Psychotropic substances; statistics for 2003; assessments of annual medical and scientific requirements for substances in schedules II, III, and IV.

International Narcotics Control Board.

United Nations Publications

2004

320 pages

$50.00

Paperback

HV5825

This report presents statistics on licitly manufactured psychotropic substances and their consumption around the world. The tables contain information submitted by governments to the International Narcotics Control Board pursuant to the provisions of article 16 of the Convention on Psychotropic Substances of 1971. Comments explain issues related to the production, import, export, and consumption of specific substances. Information is in English, French, and Spanish.

Managing a practice in today’s complex health care environment not only requires excellent clinical skills, but also superior business skills. To help practicing physicians better understand the business side of medicine, the American College of Physician Executives has developed a new, completely online, Practice Management course.

Similar to ACPE’s Practice Management Institute offered live at the Spring Institute, this Web-based course allows participants to learn without the expense and hassle of travel. Busy clinicians do not need to leave their practice or their families to gain skills to improve clinical and financial outcomes of their practice.

* How to interpret and use financial tools to measure and improve your practice’s profitability

* Ways to avoid billing and coding mistakes that may be costing you lost income

* Proven methods to improve quality and clinical outcomes

* The business secrets that America’s best practices are using to provide excellent patient care

* Practical, hands-on ways to boost your bottom line through more efficient scheduling, staffing and time-saving technology

Participants will also receive templates and worksheets to put to use right away in their own practices. Physicians, office managers and staff are welcome to participate in the course and take advantage of the expert insights.

Lastly, every participant will experience the multimedia, e-learning package, “Secrets of America’s Best Medical Practice.” They will learn invaluable tips on staffing, scheduling, technology integration and responding to changes in patient preferences. Companion manuals show how to turn a medical practice into a market leader.

[ILLUSTRATION OMITTED]

For more information on this exciting new course go to www.acpe.org/interact

$750 members

$825 non-members

20 CME

$500 members

$575 non-members

14 CME

Computer-based medical systems; proceedings.

Symposium on Computer-Based Medical Systems (18th: 2005: Dublin, Ireland)

Computer Society Press

2005

603 pages

$194.00

Paperback

R858

Papers from a June 2005 symposium describe recent research in medical imaging, biomedical signal processing, network and telemedicine systems, knowledge-based systems and data mining, decision support systems, and biomedical data analysis. There is also information on medical databases and information systems, medical image analysis, intelligent data analysis of electrocardiogram data, wearable systems for homecare and personalized healthcare, intelligent patient management, and grid computing for biomedicine and bioinformatics. Some specific topics are Markov model-based clustering for patient care, and a wearable ECG-recording system for continuous arrhythmia monitoring in wireless tele-home-care. There is no subject index.

The British Medical Association (BMA) has proposed a 17.5% Value Added Tax on foods with a high fat content in a bid to fight obesity in the UK. A GP’s conference this week is set to discuss a motion by Dr. Martin Breach which was quoted by BBC News Online as saying: “Given the epidemic of obesity related disease in the UK, this conference strongly supports the concept of a tax on saturated fats, in effect a VAT on fat.”

“The UK is facing an epidemic of obesity and obesity-related disorders,” said Breach, who is on the BMA committee. “A fifth of men are obese and very nearly a quarter of women in the UK are obese and this figure is expected to rise further.”

Obesity-related health problems, such as diabetes, heart disease and high blood pressure, cost the National Health Service over $825.9 million a year. All other EU countries except Ireland currently impose varying degrees of VAT on food. In the UK food is exempt from VAT, except for hot takeaways such as hamburgers.

Opponents of such a tax say it would hurt low-income families who tend to eat proportionally larger amounts of cheap, high-fat food.

Meanwhile, a similar tax has been proposed in Australia by the Australian Medical Association. Vice-president Mukesh Haikerwal said a tax on fatty food could be the “shock tactic” needed to solve the obesity problem, reported the Herald Sun.

It’s no longer enough for a healthcare organization to expect, or even to derive, only clinical benefits from a software system. The software system that works clinically for patients and doctors must also work financially for hospital and healthcare network administrators–and in fairly short order, too.

PROBLEM

Rush University Medical Center, a Chicago hospital of nearly 700 beds, has been cited nationally in U.S. News and World Report as one of the best hospitals in the U.S. While the institutional side of the healthcare organization was fiscally healthy, our emergency department (ED) was hemorrhaging cash. We estimate that it might have lost $500,000 to $1 million per year–and “estimate” is a key word.

Our clinicians and administrators knew that the ED had problems with door-to-doctor times, wait times within the ED, throughput and comprehensive documentation that captured and coded services for billing. But without an automated system to accurately measure the problems, everyone guessed at their extent–and damage.

Our emergency department is staffed with 19 attending physicians and 60 nurses, and handles about 42,000 patients annually. Approximately 12 resident physicians representing various medical specialties rotate through the ED each month. Until 2001, nurses and physicians documented with paper, using homegrown chart templates that might generate a single page documentation of a patient encounter.

ED staff tracked patients with a large grease board that accommodated little more information than the patient’s name and the name of the clinician treating him. We might know which room the patient was in with the grease board, but not other staff available to treat him and not the status of clinical orders related to his care. Financially, physicians’ collections needed work; the ED had operated at a deficit for many years.

We might have lacked clear metrics about our problems, but our objectives were clear. We wanted to capture more data to clinically improve treatment. We wanted to reduce waiting room times, use collected data for process improvement and quality assurance, and better capture interactions between patients and physicians. We knew that the automated capture and reporting of data would favorably influence financials.

SOLUTION

The medical directors before us at Rush also knew that the organization needed an automated emergency department information system (EDIS), and they had identified ibex Pulsecheck from Rosemont, Ill.-based ibex Healthdata Systems as the system they wanted. Unfortunately, the funds weren’t available.

We came to Rush in 2000 to direct and improve its clinical ED performance, and not acquiring an EDIS would have been a deal-breaker for us. We, too, selected the ibex Pulsecheck system, in part because it was designed by an ED physician. With our advent, the funds were forthcoming. We went live with the system on July 1, 2001, and we have experienced no downtime since.

Our implementation was relatively painless. The first two weeks were challenging because we had more than 80 clinicians using the system, all with varying degrees of computer fluency. We had set up in-service training sessions for doctors and nurses, but these were only two- or three-hour sessions, and no one asked for more. Beyond those training sessions and the first two weeks, ED staff had no trouble adapting to the system because it is extremely intuitive.

RESULTS

Within six months of installing the EDIS, we captured $1.5 million in additional institutional charges–and this alone was enough to pay for the system. The additional charges emanated from more comprehensive documentation of patient encounters, and also from our ability to use the system’s reports to make internal process improvements. By the end of the first year, we measured $3 million in additional charges that might have otherwise gone unrecorded–and turned the ED around from financial loss to financial gain.

The EDIS system has played a pivotal role in helping us to address other process-related issues. One of the biggest was length of stay (LOS), and we found we could use the system to influence LOS from triage forward.

Today, our overall LOS in the emergency department is about four hours, and that includes treating both the relatively routine cases as well as the most severe–and it’s an excellent LOS for an urban hospital. Our “fast track” or express area, for patients who don’t require extensive treatment, is about 1.5 hours. Overall, we have shaved one hour off the LOS of our sickest patients, and one hour and 20 minutes from our moderate-need patients’ LOS. Finally, we have reduced door-to-doctor times to about 25 or 30 minutes, which is excellent for an urban hospital.

From the beginning, we have conducted monthly ED meetings including physicians, nurses, social services and all those involved in the ED. ibex Pulsecheck allows us to not only capture and view patient clinical data in real time, but also to use that data for monthly and annual reporting so we can measure and improve our processes. For example, we identified a bottleneck in radiology. We spent too much time getting patients to radiology, too much time getting films read and too much time incorporating those clinical results into the ED treatment process–and with computerized data as support, we were able to alter our processes and improve our performance.

R857

2004-115811

0-7695-2289-0

IDEAS workshop on medical information systems; the digital hospital; proceedings.

IDEAS Workshop on Medical Information Systems (2004: Beijing, China) Ed. by Bipin C. Desai et al.

Computer Society Press, [c]2005
Advertisement

175 p.

$69.00 (pa)

Papers from a September 2004 workshop present new findings on technological and theoretical aspects of information technology applied in the area of health care. Presented in sections on applications in diagnostic and clinical decision support, health care information, e-disease management, electronic health information exchange, and ICU, papers report on innovations such as development of a clinical data warehouse, knowledge representation of traditional Chinese acupuncture points using the UMLS and a terminology model, and a rule-based intelligent ICU information system. There is no index.

« Previous PageNext Page »