Monday, March 14, 2011

Our Blurred Lines of Responsibility in the Electronic Medical Era

It was the early 1980's, budding minds eagerly awaited their clinical years in medicine after two grueling years pouring over books, workshops and cadavers. Gone were the fumes of formaldehyde replaced instead with the pungent smell of penicillin-infused carpets where nurses had primed IV lines. Teams of residents, medical students, and the omnipotent attending rounded from room to room - everyone knew who was in charge.

But back then in academic medical centers, there was an interesting twist: residents wrote all the orders on their patients. It was part of their training, to be sure, but also a critical requirement for proper patient care and communication. "Too many cooks can spoil the broth," we were told when it came to discussing complicated care plans with patients. Senior resident and attending worked together much as a commanding officer and executive officer do on board ship, so all consultation recommendations were either agreed to or rejected by these ultimate arbiters and coordinators of care.

That was then.

Now fast forward thirty years in our new era of dispersement of information, location, and personnel: the era of the electronic medical record.

Today, care can be rendered anywhere, my anyone. Increasingly we've seen the erosion of the "primary care giver" and the exploitation of a strange new concept: a "medical home" or "medical team" model. Who is in charge at any one time or episode of care is uncertain. In fact, the term "consultation" has vanished from our lexicon of billing codes in favor of a more ubiquitous designation of "level of care" and with it, any semblance of understanding of who's recommending care and who's delivering it. Increasingly, if a specialist feels strongly that an order should be performed on a patient, he is expected to write the electronic order rather than recommending it be performed. With that move, all other care-givers are out of the decision loop and instead, mere information consolidators.

The end result?

A diffusion of responsibility.

Suddenly no one is responsible, yet thanks to the wonders and permanence of the electronic record, everyone's responsible.

Many argue that since two heads are better than one, then many heads must be better than two.

But for a moment, imagine the potential disasters what could happen if the Navy ran their ships that way.



Dennis said...

I have been taking Tikosyn for the past 8-9 months and Toprol or Lopressor for many years. I had a shock storm about five months ago and decide to go to the ER to get interrogated and found that it was inappropriate but it was a Friday evening the the ER doc convinced me to be admitted as my triglycerides were elevated... really... after a shock storm? Duh. I was pretty shook up so I said OK. For no reason that I could discern the hospital Cardio guy decided to replace the Toprol with Coreg??? I refused and that was the last time I saw the guy until I was release Monday morning. I managed to get a call to my EP Saturday morning and he agreed I should not change the med. We discovered the ICD had been set to shock at 155 HR when I started Tikosyn by my previous EP and never raised after the dosing period was over, which only confirmed to me I had made the right decision to dump him. It slipped through the crack. I hold no animosity but I agree that to many cooks spoil the soup.

Margaret Polaneczky, MD (aka TBTAM) said...

Great post.

Our EMR just turned on a new feature whereby the designated PCP gets a copy of every encounter his patient has anywhere in the system with another provider (ie. specialist). I can just imagine the poor PCP being bombarded with specialist visit notes to read and, since they are in his in box, be responsible for coordinating, all from afar, for free and on his own time, since the patient seems to be seeing everyone but him.

Anonymous said...

Yeah and this is very difficult for nursing especially if ICU. Sometimes the most obvious bad is missed in the rapid fire, off-floor, multi-specialist, stealth electronic ordering (RFOFMSSEO).


Anonymous said...

Every doc will be legally responsible for evaluating and following up on any abnormalities on any page that he clicks on just momentarily in the EMR.

DrWes said...




Anonymous said...

Dr. Polaneczky:

Dealing with all the info coming in from other docs is already a big uncompensated headache for PCPs. Sounds like your system will make things worse, and, also, increase liability. Is there any pushback against this from the PCPs in your system?


John Lynn said...

Interesting move and we haven't even really seen the ACO movement be put in place yet either. Talk about spreading around the responsibility so that no one is really responsible.

Unknown said...

Captain Fisher,

The Navy, in fact, does run its ships with many people making independent decisions, all within the constraints of “standing orders”. Can you imagine the navigation officer running the engine room or the communications center? Neither can I. The Ships Captain and Executive officer work to ensure coordination occurs (with the possible exception of the XO in “Under Siege”)
Clearly, as we change to enable ourselves to work with the increasing amount of knowledge and abilities to do good and harm we’ll have to work on how we do our work and how we communicate with each other to ensure that gaps in handoffs don’t occur. This will take effort from all members of a health care delivery system to make sure that we aren’t walking on each other’s toes, but are ensuring that care remains coordinated. Who takes that responsibility will determine whether we improve health care, or continue to work in silos and remain “independent”.
Remember that Darwin didn't say the strongest survive. He did say that those most adaptable to change survive.