Thursday, November 08, 2012

On Being Bombarded

I have used the Electronic Medical Record (specifically EPIC) since 2004.  I have grown accustomed to its nuances, benefits and quirks.  There are parts about it I really like.  There are parts of it I'd like to do without but accept that they are necessary evils in our current health care climate.  I know that there will always be parts of any modified computer system that will suffer growing pains.  For any new and adapting technology this is understandable. 

But there is a little-appreciated issue that I see brewing: doctors (and maybe even patients) are quietly being buried by electronic information overload.  As a result, I believe doctors are being placed at an increased liability risk.

Let me explain.

In the past era of medicine, nothing happened without a doctor's order.  Nothing.  If you wanted a medication, lab test, invasive procedure, opportunity to participate in rehab classes - anything - you needed a doctor's order.   For the years of paper records and independent doctors offices, this work flow assured that doctors (1) knew what was happening with their patients, (2) saw their patients, (3) prescribed the proper therapy, and (4) assumed the risk for the intervention or treatment prescribed.  Information proceeded in a logical linear fashion and the doctor was always at the head of the information line.

But we are no longer in the old days in medicine.  We are in the era of near-instantaneous information flow, multi-directional electronic communication, and geographically disparate order entry by "caregivers," (think nurses, nurse practitioners, advanced practice nurses, clinic operators, registrars, etc.) who help us take messages, continue care, and order things.  In this electronic process, messages are no longer passed from just one individual to another, but rather are passed to two, three, four, or more individuals simultaneously from any one of several different clinical locations - some of which might be many miles apart.  There is an incredible amplifying effect of all of these messages, orders, and notifications -- so much so that even the most tech-savvy doctors are struggling to keep up.  In fact, it is not uncommon for a doctor these days to work for two hours on a procedure and return to the computer to find twenty or thirty new notifications, e-mails, or orders have been deposited there.  Head back in for the next case and then another thirty items appear.  Pretty soon, it's an avalanche of items.  Worse: doctors must click on each one of these notifications individually to "verify" he or she has looked at each and every single one.

Doctors understand that the reason we have to click on all these orders is because (a) no one gets paid in our system unless a doctor orders whatever-it-is and (b) someone has to be the fall guy if there's a problem with a nurse, medical assistant, or lab technician that "orders" something on behalf of the physician.  There is even a trend to auto-order things (like a pneumovax vaccine, for instance) that assure the hospital maintains excellent public reporting metrics whether the doctor ordered them or not with the order later appearing in our inbox to be clicked. 

But worst of all are the silent notifications sent from fellow physician colleagues buried amongst the other notifications. They tell of an important story, one that needs fairly urgent attention, but because people no longer pick up the phone, are not immediately noticed or highlighted. It's like a landmine sitting in a doctor's inbox waiting to be stumbled upon.

* Click* *Click* *Click* * Click* *Click* *Boom*

With all these people and devices ordering and sending, the limited number of doctors out there are being bombarded from multiple directions.   It is getting harder to keep up these days.  Orders and notices come to us on names we don't recognize or have been long forgotten.  (Computers don't forget that you saw the patient eight years ago).  And once an order is placed and acted upon without our knowledge these days, we click on the order to clear our notices and thereby assume all the legal risk for the care. 

The legal buck still ultimately stops with us.

Doctors need to speak up about this problem.  We are not in the old days any longer.  We are in the fast-paced, electronic medical record era where things happen (literally) at the speed of light.  We need the electronic medical record companies, payors, hospitals and legal community to come together to help us find a solution to this current infomation overload crisis that maintains patient safety and improves efficiencies while limiting legal risks to the doctors who are doing their very best just to keep up.



deepster said...

Totally agree! "We need the electronic medical record companies, payors, hospitals and legal community to come together to help us find a solution"
But the legal community? They'll probably help pull the pin out of the grenade for us!

Anonymous said...

Deepster's hit the nail in the head. We all need to be very careful and very afraid.

Sorry 'bout the anonymity. Don't want this up on a screen in a courtroom.

(BTW, Your blog's CAPTCHA system sucks.)

Anonymous said...

Not only docs, but everyone in medicine. I can recall when my not-old-fashioned father, a teacher. complained that the 'squawkbox' had been installed in his classroom and his learning environment was 'subject' to whatever came over the public address system.

As a pharmacist, we have these online forms for documentation of warfarin consultations. I do the consults as the pharmacist, and help advise patients based on the colleague agreement with my doctors, and the doctor orders the strength of warfarin and other anti-clotting agents as appropriate based on input, especially on recommendation from the consult, but there is a 'technician' in the midst that documents the interaction based on template. I would prefer to provide the consult documentation, but 'it' has to accommodate limited constraints of the template. Phooey. I could wring the neck of the technician in the middle sometimes about what she/he thinks is enough to add to the note (which is then faxed to the doctor).