Denominators Count, Too
March/April 2013
Editor’s Notebook
Denominators Count, Too
In patient safety, it’s usually better to a denominator than a numerator, to be among the average folks than among the exceptions that prove the rule, to be among those who represent the baseline than among the few who deviate from the norm, to be among those in whom risk slumbers, not among those in whom risk is revealed.
Kerry O’Connell joined the numerators (for whom his blog is named: numerators.wordpress.com) in 2005 when he developed a serious infection following surgery and left the comfortable realm of uneventful patients to join the diverse community of those who experience unexpected, preventable harm. O’Connell describes the pain, confusion, and loneliness of being a numerator:
Numerators have lost a lot to join this group…It was not our choice to leave the world of Denominators (those at risk of getting a healthcare-acquired infection) and many will struggle the rest of their lives to understand why.
Numerators don’t ask for much from the world. We ask that Denominators look behind the numbers to see the people, to love us, count us, respect our suffering, and help keep us out of bankruptcy, for once we were Denominators just like you.
With his parable of the Numerators and Denominators, O’Connell showed me a new way of thinking about the experience of medical harm. For me, his essay is a numerator among the extensive offerings in the patient safety literature.
At HIMSS (www.himssconference.com) in March, Farzad Mostashari used the numerator/denominator analogy in a different way, also effectively, to describe a different patient safety problem. For Mostashari, the denominators are the forgotten ones, those whose problems fly below the radar screen, unnoticed and untreated. In this parable, electronic records illuminate and potentially prevent their suffering.
As head of the Office of the National Coordinator (ONC) for Health IT, Mostashari is directing our national implementation of electronic medical records, with financial incentives provided by the HITECH Act.
In his keynote, Mostashari described why providers must demonstrate “meaningful use” of electronic records before they may collect incentive payments and included a convincing argument for engaging with patients proactively, not just in episodic office visits. He argued that what physicians learn about their practices from electronic records may reveal gaps in care, allowing them to correct safety problems that would remain hidden in paper-based systems. With paper, there is no practical way to know who didn’t return for follow-up care, who didn’t receive critical lab results, who is suffering from an error of omission.
Whether or not you have your blood pressure or lipids controlled is a coin toss in America. That is symptomatic of a broken system just as much as the errors of commission around safety.
With electronic records, it’s possible to catch people who would otherwise fall between the cracks. The information makes “the invisible [patient] visible and makes those people count.” Like a true epidemiologist, he’s excited that, at last, physicians can see the denominators—the whole patient population—and engage with them proactively to provide better healthcare.
O’Connell and Mostashari both use the numerator/denominator analogy to call for engaging with patients proactively, with compassion and care. It turns out that sometimes denominators count, too.