Informatics/Patient Safety/Inusrance/DC/Ethics Flashcards
Things to look at when evaluating websites to suggest to others:
a. beliefs and interests (is there a noticeable bias?)
b. financial support for the website
c. advertisements (are they clearly separated from the content?)
what are things to look for when deeming credible sources (authors etc)?
- who the authors are and are they clearly defined
- clear credentials that can be verifiable
- reputable publisher
- peer review process for the article
what are professional level sources?
- accessmedicine
- clinical key
- pubmed
- dynamed
what are consumer sources?
- gives brief summary that is concise for patients to understand
- mayoclinic
- medline
- webMD (questions about its authority, bias, and current data)
what can access medicine be used for?
- book chapters
- case review
- video tutorials
what can access clinical key be used for?
- conditions/
- procedures/drugs
- book chapter
- journal articles/medline
when/why is the date information on a publication important?
- some information hasn’t changed much throughout the years so date wouldn’t matter
- other information is rapidly changing so need to pay attention to these things
citing sources
- use APA
- refworks great website
- cite ALL information
evidence based medicine
- look at evidence for its validity and usefulness
- figure out what time of evidence best fits the question you are asking
what is a PICO question?
P=patient/population
I=intervention
C=comparison
O=outcome
how does one evaluate and EBM database?
- level of detail
- references and level of evidence
- update date and schedule
- authority, authorship, and editorial
- interface and organization
What is an error? What are examples of types of errors?
**type of unsafe act
error= UNINTENTIONAL actions that result in error or adverse events
ex:
slip: doing wrong action
lapse: memory failure
mistake: intended action but wrong decision
latent: “how its always been” more of a system problem
What is a violation?
**type of unsafe act
=deliberate deviation from procedures
What is the swiss cheese model?
This is a model that explains the multiple aspects that can lead to accidents occurring.
- it can include something minor like patient factors to successive things like institution factors and communication
- lots of things go wrong on the totem pole which leads to something bad happening
What is quality improvement (QI)?
=when health services aim to increase the likelihood of desired health outcomes which are consistent with current knowledge
- continuous process
- rapid cycles of improvement
Why is QI important?
- it can improve patient safety
- decrease adverse events
- decrease waste and excess costs
What is the first step in QI?
- identify the adverse event or near miss
What is the 2nd step in QI?
- root cause analysis
- develop a process map that is able to explain what happened and what should have happened (with the major and minor steps to these points in the middle)
- ASK WHY 5 TIMES!
Steps 3-6 of QI?
- change management with stakeholder involvement
- model for improvement and process for change
- plan PDSA cycles (plan do study act)
- measure the effects of the intervention
How do determine which aspect of a problem you address?
make a process map and identify the ROOT CAUSE of the problem… hone in on one thing that can be changed or altered in order to potentially see a benefit from the change
What are barriers to changes in healthcare?
- expected autonomy of HC workers
- stability of routine
- programmed behavior
- tunnel vision
- real/perceived limited resources
- too many rules and regulations in place
what are 8 steps to change?
- establishing a sense of urgency
- formation of a powerful coalition
- creating a vision
- communicating the vision
- empowering others to act on the vision
- short term wins
- consolidating improvements and producing still more change
- institutionalizing new approaches
who are stakeholders in change management?
this includes people who work directly with and are affected by the change.
doctors, nurses, admin, respiratory therapists, patients
what are the different categories of adopters for change?
a. innovators (accept right away)
b. early adopters (join when see benefit)
c. early majority (productivity gain)
d. late majority (when everything has already been figured out)
e. laggards (only when have to)—may never get there
what is the process of enacting change?
- innovation: coming up with new ideas and approaches to enact the change
- pilot: test the change idea on a small scale to see if it works; minimize risk
- implementation: test on a larger scale
- implement in 1 setting - spread-implementing in several settings
what is a PDSA cycle?
plan-do-study-act
- *want multiple one after the other**
- want the test to be small
- want successive studies to come from the data produced from the cycle “each test should influence the next”
- results should tell you if the test is promising or not
when looking at the studies and the data produced…
one should look at the needs of different departments (if on hospital scale) and/or look at trends and try to understand WHY they happened
how is communication enacted and why is it important?
- communicating with and to patients on importance of initiatives
- communicating to practitioners why its important and reminding them of the vision for QI
done by:
- patient testimonials
- contest
- weekly newsletters
how big of a problem is medical errors?
-33% of patients say that their loved one was affected by a medical error
-it is the 3rd leading cause of death in the U.S.
-its as dangerous as bungee jumping
~250,000 deaths/year
what is safety?
=freedom from harm or danger
-state of being safe!
what is patient safety?
=HC systems that minimize the incidence and impact of adverse effects and maximize recovery from such events
- prevention of harm
- systems issue! not on any ONE individual
what are some examples of medical error?
- Rx wrong med because they look similar in name and bottle
- wrong pt gets transplant
- wrong extremity has a surgical procedure
how is quality care created?
by the system that
- prevents errors
- learns from errors
- built on a culture of safety that involves every aspect of the medical team, organization, and patient
why do miss/delayed dx happen? how can it be improved?
-poor teamwork and communication
how improve?
- structure protocols
- increased supervision of trainees
- encourage feedback to providers when dx is missed
- discuss autopsies with families as gold stdrd. of dx
what are the 4 most common medications that account for ED visits for medicare patients?
- opioids
- bentos
- insulin
- anticoagulant/antiplatelet
ADE’s (adverse drug events) are the leading cause of injury in countries
what is being done to prevent unsafe surgeries?
- check in
- check out
- and timeout in the OR to identify who’s who and the patient and procedure being done
what are the 6 aims of improvement? (for safety) STEEEP
- safe: not harming pts
- timely: avoid delays
- efficient: avoid waste
- effective: match science to care
- equitable: close gap in inequalities
- patient centered
what are the 10 basic rules of patient safety?
- care=continuous relationship
- care is custom to patient
- patient=control
- info shared freely
- decisions are EBM
- safety
- transparency
- needs are anticipated
- waste is decreased
- cooperation of physicians= #1
tiple vs. quadruple aim of HC:
triple aim: better care –> better health –> lower cost
the quadruple aim has these but improved clinician experience is added which is essential to the overall outcomes for patients
what is one of the main ways that we can promote a culture of safety?
- focus on what went wrong
- most often than not the problem is system driven
- every person in the hierarchy of the system should have a voice and be heard… mutual respect to allow others to speak up [hierarchy still amongst doctors nurses, etc very much exists still]
- enlisting patient help in listening to their concerns is very important for safety
what are some predictors of speaking up?
- potential harm
- discomfort
- decision difficulty
what are some system improvements that can be done?
- PDSA cycles
- models for improvement
- lean thinking
- change management
what is moral hazard?
it is the trend towards risky behavior when you know if something happens that you won’t have to pay for it.
-insurance companies aim to reduce this by having cost sharing with policy holders to hold them accountable for some aspect of their healthcare
ex. smoking
potential as a reason for rising healthcare costs?
what is adverse selection?
those with low risk don’t purchase insurance while those with high risk do. This make premiums for these policyholders high because they do not have enough people to spread the cost of healthcare with.
- this is the idea of having more people have healthcare then premiums “should” go down.
- high premiums is a result of this
what does a premium cover?
this monthly costs pays for what it costs to operate the insurance company
- this money goes towards a pot of money that is used to treat others who are sick=benefit payout
- its like we all chip in to “share” the costs
what is the difference between a copay and coinsurance?
copay is a specific amount that must be spent. ex. $20 for a PCP visit
coinsurance is a % of the visit that the policy holder must be responsible for paying
what do you need to do if you want a low deductible?
then you pay a high monthly premium.
-the opposite is true if you want a low monthly premium
what are the basics of employment provided insurance?
A. fully insured: employer seeks out insurance company for different plans offers this to the employee for their choosing
B. self insured: the employer acts as the insurance company and an insurance company is only hired in order to control the admin stuff
what is the DC home rule?
-ability of DC residents to govern own affairs and set up a local government
what is DC’s representation in Congress?
- 1 non voting representative
- 3 electoral votes
there is a shadow government this is there are senators and representatives that are elected so if a law goes into place which allows DC to have representation they are ready to assume their position
what is the DC local government comprised of?
- 1 mayor
- 13 council members that represent each ward (chairman and 4 at large)
What is the difference between who SETS the budget and who APPROVES the budget for DC?
sets: mayor and the 13 council members
approves: US congress
* this is important because things that DC needs may not be approved by a republican congress
what are the wards of DC generally known as?
- there are 8 wards
- e. of the river–anacostia is 7/8 known for poverty, crime, housing problems, and racial segregation
- 3 is west of the park and is known for $$$ and white
- 4 is east of the park and known more for hispanics
whats the problem with northwest one?
- example of mayor fenty and gentrification efforts throughout DC
- many are displaced from their communities because they can’t afford it
- northwest one is a mixed income community with a few families from the original community living there
AA in the DC area have higher rates of
- diabtes
- obesity
- stroke
- cancer
- smoking
- heart disease
-many of this is attributed to access to fresh produce, environmental issues, preventative services available, doctor response (aka oh you are over exaggerating. or something like that)
hospital disbursement throughout DC?
- many hospitals are concentrated in NW and NE
- access to these may be difficult
- UMC (which no longer exists) was the only publicly funded hospital
- no hospitals in wards 7/8
what healthcare coverage exists in DC?
- private insurance
- public: medicare (federal), medicaid(state + federal), DC healthcare alliance (DC funding only)
What is inpatient care?
=involves an overnight stay
- acute services
- long term care
- rehab services
- psych services
What is outpatient care?
=network of services in the ambulatory setting
- preventative, specialty, and non-acute
- acute: ED before admitting to hospital
- hospice
Public hospitals
- run by state and local gov.
- federal: walter reed, VA, Indian health service
- State/local: DC sorta of has one with UMC
What are state/local hospitals?
- usually considered the safety net hospitals
- locationsL large cities, small towns, rural areas
Private hospitals
-can have non-profit, for profit (GW), physician owned
What are some arguments for for-profit hospitals? How do they make $$
- dont get tax benefits
- can split profits with shareholders/owners
$$:
- good location
- offer more specialty services
- do provide some free services
What are some arguments for non-profit hospitals?
- payment has to be circulated back into the hospital
- can pay salaries
- state/federal tax breaks
What people play an integral role in the running of a hospital?
- board of directors
- administrators
- service providers
also a # of committees: ethical, quality, and pharmaceutical committees
the trend in how doctors are employed
- many used to own their own practice now that is becoming exceedingly unsustainable and expensive
- many work as independent contractors for the hospital or medical group
What are some advantages to having doctors be integrated into the hospital?
- work life balance
- lack of overhead admin
- larger number of providers make coverage easier
- guaranteed salary
what are some disadvantages to having integrating of doctors with hospitals?
- provider can only work for one place
- provider goals may conflict with the admins
- loss of autonomy
What has the shift been in medicine of where patients get their care?
most patient visits are to the outpatient setting
- this could be a good or bad thing dependent upon who you are
- good for patients because it is MUCH less expensive to go outpatient
What are examples of outpatient settings
hospice ambulatory surgery center home care boutique services medical home complementary or alternative medicine
what is the most common reason for visit to outpatient?
cough
What is the most commonly diagnoses condition for outpatient?
hypertension
primary care and things that are good about it
- 55% of visits were to PCP
- generalists: family med, internal med, pediatrics, OB-GYN
- develop ongoing patient provider relationship
- addresses acute, chronic, and preventative/wellness issues
- PCP linked with better outcomes and long term cost savings
What is the shortage of doctors?
we will always have a job! there is a shortage nationwide
- shortage of PCP’s because they are an essential component to healthcare
- shortage of specialists due to the aging population
*there are shortages particularly in underserved areas
What are the causes for shortage?
-not enough spots for residents and not enough funding
what are some pros for limited spots?
- job availability
- set standard
- residency training is very expensive: salary, higher cost of care
what are some cons to limited slots?
- we need more doctors
- standards are too high/missing out on good candidates
- doctors are overworked
What has the OMB done in order to use race in biomedical research?
- 1997
- it revised the standards for which races to include in surveys and studies
- it expanded the number in order to hopefully capture a larger data/group
What is the NIH policy on women and minorities in research?
- 1993
- mandated that women and minorities MUST be included in ALL NIH supported research
- researchers must use the racial and ethnic guidelines described by the OMB
problems: no requirement for specific numbers, this is still weak and minorities are not a large #
What is the FDA policy for minorities?
- use OMB categories
- this can standardize demographic and subset data analysis
- encourages subgroup studies so a better understand of drug reactions, efficacy, and variation can be better understood
Whats the problem with GWAS and minority data?
- most who participate in these studies are of euro descent
- too broad of terms used for populations descriptors
What was the % of babies that were born mixed race in 2012?
50%
What is the BiDil case study?
- found that this drug worked well in blacks
- genetics were never actually assessed tho. Did this solely based upon race
- dr. still rx this drug by race but also rx it to white people
What do dr.’s think about race and genetics?
- genetics and environment = influence ethnic and racial disparities (PCP)
- genetics have limited influence on health outcomes.
- physicians may be withholding ace inhibitors from AA who may benefit from them
