Abstract
The delivery of healthcare in modern medical centers continues to be an innovative creation of a long and hard struggle. In particular, new legal reforms, practices, treatments, human resources, and in most cases finances, continue to measure the quality, cost and access of the healthcare system in the U.S. Numerous ethical dilemmas arise on a daily basis due to negative public press that increases fear in our communities and healthcare professionals regarding the relationship between excessive malpractice and insurance premiums against successful treatments or medical procedures. Consequently, we live in an era in which we have different levels of priorities, expectations and interpretation about balancing mistakes with success in the entire healthcare systems in America.
Malpractice Management
It s no secret that the beginning of the health care history has proven to be evolutionary, and in particular, a recurring subject has been malpractice mostly in the form of infection control due to environmental conditions and the elements of negligence. Up to now, malpractice is the eighth leading cause of death in America, accounting for roughly 250,000 deaths and billions of dollars of associated costs directly related to those who remain in pain and disabilities (Sternberg, 2016). Consequently, the objectives of the Tort Law were established to protect individuals against malpractice for which a court provides a remedy in the form of an action for damages. However, the question is to what extent can the Tort Law protect individuals? Certainly, the risks are high and doctors basically are applying the empirical law it is better to be safe than sorry , which means that although accessibility to care is more abundant through numerous of medical centers in different specialties, physicians find it a necessity to limit the number of patients and which patients they treat in order to protect themselves against any form of negligence , all under their own interpretation of standard of care terms, conditions and procedures, which creates a problem as increased access leads to fewer patients and high healthcare cost for those who can afford it (Tilley, 2017). However, as long as there are humanitarian desires there will always be healthcare organizations to treat our health care needs. The need for doing good, showing compassion, and helping others is key to meeting the needs of our communities, and it requires the courage to persevere the good and passion to create an even better health care system that seeks to resolve important principles of ethical issues of justice to the forefront, as individuals, communities, and the legislatures struggle with how to provide quality health care for many without sacrificing the basic rights. One approach that seeks to resolve this issue is the implementation of the Malpractice Reform, which helps doctors feel more comfortable in high-risk situations, which means that under certain circumstances, damages are capped, leading to better patient outcomes and possibly helping improve successful treatments, high insurance premium control, and malpractice claim prevention (Carroll, 2017).
Malpractice lawsuits have dramatically raised the cost of health care for everyone by forcing physicians to practice defensive medicine by adding procedures, test, and treatments, which could be optional. Consequently, the number of successful treatments has decreased and many physicians have turned to integrated medical centers in which they impose their own terms and conditions in order to protect themselves against malpractice lawsuits. In turn, this has become an issue due to the high costs of excessive tests during the medical treatments or procedures necessary to provide, sometimes, a simple consultation. Therefore, the continuing stream of high financial consequences in health care service has dramatically impacted the accessibility to care for most Americans (Kessler, 2011). It is important to highlight that a tort is being defined as a civil wrong by a person, where there is a duty to act in a different manner, and where the result is injury or harm to another individual. There are three basic categories of torts: 1) negligent; 2) intentional; and 3) strict liability, in which the duty to care is a key differentiator among these different categories of torts. In practice, the tort system is designed to provide compensation to those persons injured by civil wrongs. Also, the tort system is intended to discourage the wrongdoer from committing future wrongful acts from appropriate standards of care. With the elements of negligence, the emphasis is upon how adequate a person should act, which directly correlates to a matter of a situational ethics, but with the forms of negligence, the standard of care is much more complicated. The emphasis with medical negligence is on how a reasonably competent and skilled healthcare associate should act under a given situational circumstance.
Consequently, due to different priorities and expectations of very high standard of care, malpractice always results in dramatic remedies in the form of action for damages; for example, financial damages, which compensate those injured persons for the cost of necessary medical care, and those for pain and suffering. Those people with remaining pain and suffering are very complicated to quantify; and, potentially, far exceed the monetary award of financial damages (Pozgar, 2016, p. 64-72) & (Kessler, 2011). This is a threat to health care quality for all Americans. Increasingly, Americans are at risk of not being able to find a doctor when they most need one because physicians have turned their attentions to defensive medicine resulting in very high cost for all patients even for those full insured. In addition, excessive lawsuits are making it impossible to improve the quality of care as medical centers, physicians, and nurses are reluctant to report problems and to participate in joint efforts to improve care because they fear being involved in lawsuits, even if they did nothing wrong. Financial damages should be capped to help healthcare associates feel more comfortable in risky situations, leading to better patient outcomes and possibly controlling the ever-rising health care costs in America.
When it comes to a healthcare delivery in America, there are four fundamental objectives that shape the system. 1) quality health care that can provide the greatest benefits; 2) freedom of choice so that individuals can decide who and where will deliver health care; 3) affordability so that individuals have the resources for all the other things they need or want. 4) share in the costs and also benefits of health care. However, as mentioned above, even though our communities and societies in America share the same common values when it comes to health care, there are different priorities, expectations, and interpretations. In addition, it is important to highlight that justice in our societies is the obligation to be fair in the distribution of benefits and risks for all individuals, and it demands that everyone is treated equally under similar circumstances (Pozgar, 2016, p.39-42). Our current health care system in our society appears not to be fair in the benefits and risks when it comes to malpractice, all as a result of priorities, causing very high prices in both insurance premiums and malpractice insurance. In order to reduce these insurance costs and to treat everybody fairly, it is necessary to implement the Malpractice Reform, which protects individuals from having to pay the high costs of malpractice insurance and increase accessibility to more health care services, and in return, physicians will be more willing to adapt to larger changes in the health care system (Corapi, 2014). However, injured individuals argue against the Malpractice Reform, saying it will prevent patients from being protected against negligent physicians. This is a very complicated subject in which many experts argue that the Malpractice Reform is ambiguous, and in the long run will only increase the cost of insurance as reducing liability could increase costly medical errors and encourage providers to recommend profitable, but unnecessary and even risky treatments, increasing health care costs and lowering the quality of care (NBER, 2017). Healthcare politics among leaders must be understood and share a passion to develop a better system to avoid high cost in insurances, and in addition, Congress has to make a reasoned decision in terms of defining justice in our health care system.
Certainly, one of the historical and controversial issues in our health care system today is the malpractice, and the great majority of malpractice is in the form of infection control issues in health care locations. Although technology has improved the health care delivery system in America, today s healthcare challenges still include excessive malpractice awards due to medical lawsuits, high expectations of society for miracle drugs and miracle cures, which blocks the efforts to improve quality of care. An approach to balance mistakes and successful events is the effect of Malpractice Reform, which attempts to cap non-economic damages in medical malpractice lawsuits, thus releasing the providers from problems that are not precisely theirs and addressing a serious cause of higher medical bills (Carroll, 2017). In addition, in order to win a medical malpractice case, a plaintiff must prove four findings, according to the elements of negligence. 1) Duty to care is an obligation to conform to a recognized standard of care, which means that there is a relationship between the doctors and patients in which doctors owe the duty of care to patients; 2) breach of duty is a deviation or failure to adhere to an obligation from the standard of care, which means the plaintiff must prove that the physician breached his duty to the patient. However, a physician is not necessarily negligent if his efforts are unsuccessful or if he makes a mistake as this negligence is directly dependent on a situational standard of care; 3) injury is realized when the plaintiff proves that the physician s action led to a damage; 4) causation is realized when the plaintiff proves that the patient suffered harm as a result of the breach of duty (Pozgar, 2016, p.66-72). As a consequence, any unproven element of negligence will defeat any lawsuit. However, according to Aaron E. Carroll:
Research shows that providers and hospitals spent $81,000 to $107,000 to defend cases that went to verdict, on average. Even defending claims that were dropped, withdrawn or dismissed cost $15,000 per claim (Carroll, 2017).
Therefore, malpractice claims can be prevented ultimately at the expense of the patients, which have to absorb the high cost of health care just to receive treatment.
Electronic Health Records (EHR)
The Health Information Technology for Economic and Clinical Health (HITECH) Act allocated $27 billion to support the meaningful use of Electronic Health Records (EHRs). It estimated that 70% of healthcare professionals will use EHRs by 2020 and that is eventually would improve the quality healthcare outcomes and reduce the healthcare spending (Victoroff, Drury, Campagna, & Morrato, 2013). There are Medicare and Medicaid EMR Incentive Programs support HITECH Act and encourage healthcare providers to use electronic medical record properly and take the advantages from its benefits to reach levels of high quality of care. These programs offer incentive payment to qualified professionals and qualified hospitals who implement, update, and prove meaningful use of certified electronic medical record system. Qualified professionals can take up to $44,000 through the Medicare EMR Incentive Program and up to $63,750 through the Medicaid EMR Incentive Program (Affordable Care Act Implementation and Information, n.d.).
The meaningful use of EHRs would not only improve the healthcare outcomes, minimize tort claims, and enhance the patients safety, but also reduce medical liability and malpractice by healthcare providers. That led some malpractice insurers to offer discounts and lower premiums to healthcare providers who use EHRs. Electronic documentation strengthens the accuracy of courts in determining liability by enhancing the evidence available to assess malpractice claims (Mangalmurti, Murtagh, & Mello, 2010).
The healthcare providers must consider the EHR design before the implementation as the poor design EHR increases the medical errors and malpractice claims which raises the medical liability and decreases the quality of care while increasing the cost (Mangalmurti, Murtagh, & Mello, 2010). There is a model for EHRs adoption required by the Health Information and Management Systems Society (HIMSS) that aims to measure the adoption stage by healthcare
organizations. It is an eight-stage model that used to evaluate the EHRs capabilities and functions and describe the EHR components. This model helps to improve the performance and reduce medical malpractice liabilities. The stages are numbered from zero to eight as follows (HIMSS analytics, n.d.):
Stage0: the healthcare organization doesn t have ancillary department systems such as laboratory, pharmacy, and radiology systems.
Stage1: the healthcare organization installed ancillary department systems.
Stage2: the healthcare organization installed clinical data repository system (CDR) that allows physicians to review patient s orders and results electronically. It must also include health information exchange(HIE) which enables healthcare professionals to share health information with other stakeholders and facilitates electronically.
Stage3: the healthcare organization installed the Clinical Decision Support System (CDSS), Electronic Medication Administration Record application (EMAR), and Picture Archive and Communication Systems (PACS). CDSS provides clinical practice guidelines, clinical reminders, drug doses check, and safety alerts. PACS allows access to the medical images from outside the radiology department.
Stage4: the healthcare organization installed the Computerized Practitioner Order Entry (CPOE) which allows physicians to enter the medications and the system automatically check if there is any drug interactions, allergic reactions, or errors
Stage5: Full R-PACS is installed by the healthcare organization and used by healthcare professionals.
Stage6: Full physician documentation with structured templates and Fall CDSS are installed by the healthcare organization and used by healthcare professionals.
Stage7: complete EHR is implemented and meaningfully used and data warehousing is used to analyze patterns of and trends in the healthcare organization. That EHR would eventually improve quality of care, patient safety, and care delivery efficiency.
After successful implementation of EHR systems, the adverse events and medical claims would be reduced as it would significantly reduce the medical errors, improve the medical decision especially with clinical decision-support system, improve documentation of clinical decisions and activity, improve patient satisfaction, improve patient communication (Mangalmurti, Murtagh, & Mello, 2010).
Although the meaningful use of EHR significantly reduces the malpractice claims, it raises different kind of liability and legal risk that may relate to the privacy and the confidentiality of electronic health information. Electronic data is always prone to lost or damages during data entry, displaying, or transmission which negatively affect the information integrity. Unfortunately, health information is very sensitive as any error could harm the patient or cost his or her life (Bowman, 2013). The liability insurers and courts must be educated about the EHR associated risks and its potential limitations.
Healthcare providers are responsible of properly managing EHRs and its potential risks by many ways. For instance, they must carefully use the EHR system that is easy to use and aims to minimize the risk of user error. After selecting and implementing EHR system, it is important to make sure that the healthcare professionals are understand EHR goals and importance. They must be trained to use it and technical support staff must be hired to solve EHR issues. The healthcare professionals use of EHR must be monitored and evaluated to detect its potential problems and issues. They also must know that using EHRs can protect them from liability, and how misuse can increase liability risk. In addition, healthcare providers must discus and consider
the malpractice implications of EHRs and compare the cost of EHR implementation and its possible risks with its long-run benefits to ensure that it is cost-effective choice to improve the healthcare outcome (Mangalmurti, Murtagh, & Mello, 2010).
The Robotic IV Automation system
According to Kessler (2011), the medical practice liability system in the United States seeks to achieve two purposes. The first is to pay off patients who have suffered as a result of negligence in the hands of physicians and other care givers, and the second is to find ways to prevent care givers from negligence during provision of health care. The statistics on malpractice claim have reduced and stabilized in the past decade, as compared to decades before. Between the 1960s and the 1980, there was a surge in the number of malpractice claims against physicians and the amount of compensation given per claim. From 1990 however, the claims narrowed to about fifteen claims for every one hundred physicians, even though the amount of compensation given seemed to rise twofold in the decade that followed. Many physicians typically insure themselves against malpractice claims. The insurance covers the cost of legal suits as well as the compensation awarded. However, it is necessary to find a long-term solution to avoid malpractice claims. Technology can play a significant role in malpractice reform. The use of robots and artificial intelligence can drastically reduce human errors in patient care, thus reducing malpractice and negligence claims.
The Institute of Medicine argues that many medication errors result from the following negligent practices:
i. Inaccurately writing down or reading medicaments. Illegible handwriting and confusion may lead to issuance of wrong dosages.
ii. Failing to access the dangers that may arise due to prescription of a new drug where a patient is on other prescriptions
iii. Issuing the wrong prescriptions
iv. Incorrectly setting intravenous system (Young, 2010).
In 2014, St. Barnabas Hospital in New York joined a list of hospitals adopting advanced robotics systems. The system that was adopted by St. Barnabas Hospital is called the Robotic IV Automation (RIVA) system, developed by a company called Intelligent Hospital Systems (Scarborough, 2014). The robot helps in filling syringes, sanitizing drugs and offering precise amounts of medication. The robotic system comes in handy in general care provision, chemotherapy and areas of care where there is need for high levels of sanitation such as the Intensive Care Units (ICU). The Institute for Medicine estimates that over seven thousand people die annually, millions develop health complication, and over three and a half billion dollars are lost due to human error in health care (Scarborough, 2014). The robotic system thus ensures that the human error component of health care provision is reduced to the minimum.
According to the company s description of the system, RIVA addresses the issues of safety for the patient and the pharmacy technician, efficiency and effectiveness in the pharmacy and the challenges of a changing regulatory environment (ARxIUM, n.d). The robotic system uses advanced safety features and procedures, comprehensive electronic inspecting, and incorporation to existing hospital systems to see to it that pediatric, newborn infants, and grown-up patients are given the correct dosages. The system s efficiency and effectiveness also allows medical institutions to redeploy staff since it is incorporated into the pharmacy section, increasing the rate of filing orders and eliminating the requirement for pre-filled drugs. Moreover, the Robotic IV Automation system is compliant to all the present regulations such as USP<797>, NIOSH, OSHA among others ARxIUM, n.d).
The Robotic IV Automation system was voted the best performing intravenous robot in 2016. The robot developed by Intelligent Hospital Systems, also called ARxIUM had an overall performance score of eighty-six, twenty percent points more than the second ranked robotic system. The award, given by the research firm KLAS, recognized the RIVA system as the leading robotic system in accuracy, reliability and patient safety. The system also ranked highest in increasing productivity of caregivers and reducing medical expenses by reducing wastage (ARxIUM, 2016). The system thus comes in handy in reducing excessive malpractice claims. The system helps in dealing with key areas where care givers are found guilty of negligence and charged for malpractice.
The robotic system s parent company Intelligent Hospital Systems claims that medical institutions that install the robotic system, through the cost saving measures, get their return on investment in less than thirty-six months. These cost saving measures include; reduced wastages in administering dosages, reduced cost-per-dose of drugs administered, eradicating medication outsourcing. Thus, hospitals, in less than three years can recoup the amount spent of procuring the robotic system, while enhancing provision of care through use of machine (ARxIUM, n.d).
Of critical importance, in line with the scope of this paper, is how this technology helps in malpractice reform by reducing negligence which may lead to malpractice claims. The system is efficient since it negates the need to manually transcribe medication to be read by another party. As mentioned above inaccuracies result from incorrectly written dosages or incorrectly read dosages. These negligent errors can lead to legal suits on malpractice. The RIVA system s comprehensive electronic inspection also reduces instances of doubt. Every transaction, process and event leaves an electronic trail that can be referred to later, in case of doubt or any other need.
Whereas the robotic system doesn t come cheap, the economic side of acquiring the system is a no-brainer. The parent company estimates that buyers typically recoup their investment in less than three years. Moreover, the instances of negligence that are reduced or abated by the machine mean that the economics deem it worthy as compared to not having the system. Malpractice claims are expensive, both to physicians, insurers and medical institutions. On top of the monetary compensation, hospital s brands are affected by malpractice suits, the physicians credible is put at stake, leading to lose of valuable and talented workforce. The use of systems such as RIVA is consistent with the attitude of physicians and other caregivers about the use of robots to assist in provision of care. According to a research finding by Medical Express, more than three quarters of the surveyed surgeons expressed general acceptance in the use of robots if the robots lead to better efficiency in surgery. A further eighty six percent said they would adopt robots if the systems lead to fewer cases of unintentional harm to a patient (Jaiprakash, Roberts & Crawford, 2017).
Whichever way one looks at it, robots are a crucial component of health care provision. Robots help eliminate human errors which account for significant mishaps that take place during care provision. The advantage of robots is that in addition to reducing harm and increasing efficiency, they reduce wastage of medical resources, thus effectively helping recoup the funds spent in procuring the systems. There is need for adoption and innovation of more robotic systems that will aid in provision of medical care.
CyberKnife machine
It is known that technology drains a huge amount of money, however, there are some machines that cost more than an individual s expectations. Some of them are used to improve people s health like the machines that are used for those who suffer from cancer disease, kidney disease, and heart attack disease etc. On the other hand, there are some machines that people go for just to enhance their appearances like, plastic surgeries, cool-sculpting machines, and LBG etc. Health care organizations depend on health insurance to cover most of the individual s costs. Nowadays, some of the most considerable questions are, who should decide, which type of machines are the most effective and should be selected for every disease without ignoring the huge expenditures? Should (HCOs) care about the patients first, or consider the prices and the patients at the same time? For example, if the health insurance cannot cover all the amount of money spend on these kinds of machines, how the (HCOs) should act to be at the safe side?
CyberKnife is one of the machines that drains a lot amount of money, and at the same time, it is considered very helpful and effective for those who suffer from cancer disease. It is the world first robotic radiosurgery system. It is very efficient and precise and involve no cutting
(Lyfboat Blog,2016). In 2005, more than 18,000 treated by CyberKnife worldwide, over 130 papers published to suggest its effectiveness, and over 140 health care institutions have selected CyberKnife as to be one of the most effective machines for cancer disease (Mygenesishealth.com, 2005). It was confirmed by the Food and Drugs Administration (FDA) to treat tumors in most parts of the body. Unfortunately, in some states and other places, Medicare does not cover the treatment that is done by CyberKnife machines because from their prospective, there are not enough studies that suggest the effectiveness of these kind of machines (Soul, 2017). However, there are a lot of studies that show its effectiveness. According to Cyberknifeforum.com, 2017, CyberKnife is used around the world due to its effectiveness in treating different types of tumors.
Regarding the cost and reimbursement of CyberKnife, the organization is the one that should decide how much the treatment cost because everyone is treated differently. The patient may be covered by a privet entity or by a Medicare plan, however, there are some planes or guidelines for those who suffer from this disease that might restrict their treatments, which becomes very difficult for the organization to decide what they should do for the patient to treat them by CyberKnife. The most difficult situation for an organization is when the patient does not have any entity to cover him/her, but there is a necessity to get treated by the CyberKnife.
Geographically, CyberKnife makes debatable issues in some states. Medicare pays for the treatment by CyberKnife in 33 states, however, it does not pay in 17 others like: California and Texas which are considered two of the biggest states beside the other states like: Alaska, Colorado, Hawaii, Montana, New Mexico, Oklahoma, Oregon, Virginia, South Dakota, and Nevada which are also do not get paid by Medicare. Getting treated by CyberKnife is not cheap as most of what people argue since it might reach $29,000. However, it can be cheaper than the other radiation machines that cost $ 50,000 (Soul, 2017).
Individuals who have cancer, most of the time feel depressed and frustrated due to the unsatisfied results that might appear on their bodies while getting treated by most of the cancer machines. When it comes to use any type of machines for those who have cancer, it is very serious to select the right decisions for the patients and the right machine. Both chemotherapy and radiation can have unpleased side effects, however, there may be other alternative options to treat cancer with less side effects like CyberKnife machine. While it is considered robotic which means that it could identify the exact cells that have tumors to kill them, other traditional machines need the therapists to identify the cells by themselves that must be removed. They might select the wrong cell to kill, especially, the cells are super small in their sizes and they are moving. Furthermore, other traditional machines need highly doses of radiation which are set by the therapists too, certainly kill the nearest cells of the cancers since it is very difficult just to trace the effected cells and that might contribute to increase the side effects (Chu,2017). CyberKnife unlike the others, it can precisely give the exact dosage to the exact cells that are needed to be killed and removed, particularly, the cells are always moving.
Memorial cancer institute is considered one of the biggest cancer centers in South Florida and it has selected this machine to treat its patients. Below are some statistics about the number of the patients that the institution has treated them so far:
It can be seen from the pie chart that CyberKnife has been used for the patients with brain cancer and lung cancer the most, which are a lot of people suffer from. Following them there are some people who have other types of cancers, which also are treated by this effective machine.
One of the most crucial questions might be, why other organizations should select this machine to treat their patients instead of other machines? Since these days there are many people get affected by this disease and the number is growing so fast, there must be restricted interventions that try to help to reduce it or control it by setting some protocols while dealing with huge and expensive machines and at the same time putting the patients as one of the priorities. In fact, there are some characteristics that are existed on CyberKnife that other technologies do not have. First, it is stereotactic, and that means it could navigate and trace the cells that are moving to kill them. Second, it is robotic, and that means it is faster than the therapists and flexible while moving. Third, it is precise, and it means that it never selects the normal cell to kill. Finally, there is no needs of surgeries. Although the other machines could treat a lot of patients without needing surgeries, there are some limitations and in some cases the process of the treatment are still difficult for the patients to handle. For instance, some of these machines called GamaKnife, and if the patient has brain cancer, the first thing that therapists must do is to attach the head with a frame that has4 pins. That should stabilize the head during the process (Mayo Clinic, 2017). It is very difficult for anyone to imagine that; the frame must be put in his/her head to get treated from cancer disease. For these reasons, selecting CyberKnife is better than any other machine because of its characteristics.
In conclusion, while medical malpractice continues to be one of the leading causes of death in the United States, the adoption of EHR, and technologies like CyberKnife and the robotic IV automation system have reduced the rate of occurrence while medical reform has reduced the overall number of lawsuit that could lead to the physicians practicing defensive medicine or reduce performing high risk procedures.