No one likes to hear, “You’re doing it wrong.” This kind of criticism is even more difficult to deliver if the work in question involves life and death decisions. Peer review among doctors falls into that category – vital but difficult.
David F. Jadwin, DO, has built a system to make this kind of feedback quicker and less painful for everyone involved. He founded Columbia Healthcare Analytics, Inc. in 2006 and has been working to change how blood transfusions are used ever since.
Jadwin’s goal for the analysis process is to identify bad habits that doctors have picked up over time and educate them through case management review. He wants every hospital to be able to review every decision to give a transfusion and to help doctors actually follow best practices.
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“This system is disruptive because it doesn’t require an EHR,” he said. “We’ve been waiting for the magical healthcare record to swoop in and solve all our problems, but that’s not going to happen.”
Jadwin says this kind of review is the single most important thing the health system could implement nationwide to have a uniform impact on the quality and cost of care.
“If you tackle quality, the costs will take care of themselves,” he said.
His company offers “External Review as a Service.” He describes the process as peer reviewed, highly controlled and very protected.
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Here’s how it works. The company trains a person to extract the relevant data from a chart. First the person redacts all identifying information, even the doctor’s signature. Vital signs are color coded and the information is linked back to the source document. Then the person goes through the narrative reports and puts certain care events into a timeline. At this point, a doctor reviews the transfusions and puts them into one of four color-coded categories:
- Avoid – pink, transfusion was completely unnecessary
- Defer – yellow, not inappropriate but not life-saving either
- No exception – green, a good decision
- No critique – blue, not enough information to make a judgement, possibly because the medical record is incomplee
This analysis is then presented to the doctor who provided the care to reinforce best practices around when to give blood to a patient. This system standardizes the review process and provides educational feedback to physicians about their case management.
Doctors could earn CME credit or earn a small fee for doing this work. You can see examples of the analysis on the company’s blog.
Jadwin has served as a chair of pathology in three hospitals, so he understands the dynamics of peer review. Doctors doing the reviews would be looking at charts from another hospital, not from the people they work with every day.
“No one will be able to claim they are being picked on,” he said. “It also creates a level of transparency.”
Marin General Hospital (235 beds) is entering its fourth year of 100 percent chart review. During the first year of the review, Marin saved $861,000 in blood supply costs.
“We find that 30% – 50% of transfusions are not beneficial and 15 – 25% fall in the avoid category,” Jadwin said.
Phase 1 of pilot project with Marin was a study of 100 charts.
“There was a 30% reduction of blood use in first 90 days, and overall they reduced blood use by 50%,” he said. “Thirty days later they launched 100% chart review.”
Jadwin has run pilot projects with 26 hospitals across the country, including HCA, Tenet Health, Catholic Health Initiatives, Dignity Health and Ascension Health. He has found that the number of non-beneficial transfusions per patient ranges from 1.1 to 2.9 which translates to an avoidable cost of $1,400 to $3,400 just related to blood. These costs often are due to treating transfusion reactions resulting from unnecessary blood use and increased length of stay resulting when patients are over-transfused.
“Savings in blood costs alone could underwrite the review of all records,” he said.
Jadwin said that for a pilot project he charges $175 per chart to start and recommends that large hospitals analyze 100 charts initially.
“I have talked to hospitals that won’t even spend $500 to initiate this,” he said.
Jadwin said it has taken up to 5 years for hospitals to return a phone call, but after doing this work for eight years, he now has a fair number of hospitals in the pipeline.
Jadwin doesn’t want to sell this analysis system to an HIT company. He’d like to see a professional society take it on and get more hospitals to use it. The society would run the review process and decide how the charts would be reviewed.
“The professional society could be paid as much as $50 per chart, which could become substantial annual revenue for overseeing the process,” he said.
This process could be used to perform peer review of any hospital service, with a goal of establishing peer review networks around the country.