Groundhog's Day and Déja Vu All Over Again

Nov. 11, 2011
This being Groundhog’s day, I thought it might be fun to post a set of issues that seem to come up over and over again – seemingly never to be solved, and often involving the same arguments, if not precise language with each passing year. Sadly, these issues don’t seem to go away with increasing utilization and improvement of technology. Indeed, as the technology gets better, it seems these arguments are heard with increasing frequency. So, over the years I’ve been involved in using data to improve quality, here are some of the issues I’ve heard from clinicians over and over and over.

In the 1993 film Groundhog Day, Bill Murray plays Phil Connors, a character who finds himself in the unenviable position of awaking day after day to the same (Groundhog’s) day. The memories of the day before are still fresh, but the calendar date has not changed.

This being Groundhog’s day, I thought it might be fun to post a set of issues that seem to come up over and over again – seemingly never to be solved, and often involving the same arguments, if not precise language with each passing year. Sadly, these issues don’t seem to go away with increasing utilization and improvement of technology. Indeed, as the technology gets better, it seems these arguments are heard with increasing frequency. So, over the years I’ve been involved in using data to improve quality, here are some of the issues I’ve heard from clinicians over and over and over.

· “It’s not my patient.” It never ceases to amaze me the degree of difficulty involved in determining just who was responsible for the care of the patient. Over the years, the arguments have not changed very much: “I signed the discharge, but I was just on call for the weekend.” Well, yes I was the attending, but Dr. Major Bowel did the surgery.” “Yes, I discharged the patient but I only had him/ her for three days. Dr Before Me had the patient for almost a month.” I wonder how most patients would feel if they understood that it is not at all unusual to find that no one can actually agree who is ultimately responsible for the patient’s hospital stay.

· “My patients are sicker” This argument is as old as data itself and the proliferation of risk adjustment methods, 30 day vs. in-patient mortality, and outlier trims, has, if anything, made the problems worse. I have often been told that the observed outcomes are not correct because “my patients are sicker.” I have yet to have anyone call me to complain that his or her outcomes actually are not as good as indicated because the patients were not really that sick after all. Common sense dictates that if the argument were truly about severity of illness, the distribution of complaints – sicker / less sick – would, in fact, be random.

· “These costs are wrong.” Yes, it seems the costs are always wrong and this is an argument loved by clinicians and finance types alike. There seems to be no way to actually account for the cost of care. Pity the poor fool who expects anyone to take seriously a cost based off of a cost to charge ratio, even though by law, there must exist somewhere an audited financial statement of costs and charges. Inadequate too, are numbers derived directly from the cost accounting systems as many times the charge masters are not detailed enough to get down to the particular device manufacturer, for example. Even though the costs in question might be two or three times the cost of a best observed practice, they are dismissed as useless at best, misleading at worst.

The point of the three Groundhog’s Day examples above is that technology alone will not fix these issues. No matter how detailed or advanced the electronic medical record becomes, physician attribution, severity of illness and estimating costs are problems that remain. Most of the time, solving these require socio – political decisions not technical ones. That is, can the medical staff adhere to a set of rules and conventions around physician attribution? Can clinicians reach a consensus on a methodology for risk adjustment or we will spend precious time and energy on “method wars?” Can we agree upfront what are fixed and variable costs, and can we stipulate a margin of error?

So EMRs may come and go. Use may get more and more meaningful, but like Groundhog’s Day repetition, these issues will remain.

Perhaps these items have resonated with you. These are but a few examples of the repeating conundrums; I’m sure you have your own set. I invite you all to post your own favorite “Groundhog’s Day” questions or issues.

Perhaps we will revisit them next year at this time and see what, if anything, has changed.

Happy Groundhog’s Day

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