The Level 2 Inpatient Encounter

Ever what a doctor needs to type for a 20-minute inpatient visit? Here's what it took me:

(Note: my poor typical skills are evident in the repetitive pounding on the "Delete" key...)

-Wes

P.S.: Here's the data from a carefully-conducted "study" on age vs. typing skills I conducted some time ago.

Cybernetic Medicine

Cybernetics, the scientific study of control and communication in the animal and the machine, used to be the stuff of science fiction.  Today, thanks to a Faustian bargain between corporations, regulators, and politicians, it is defining medicine.

Every day, the exponential explosion of data entry and regulatory requirements doctors endure boggles the mind, all in the name of "health care." 

Feedback is critical to field of cybernetics.  And when Medicare's straps have you by the balls, you comply.

No longer is it good enough to learn a diagnosis or procedure code, doctors must attend online courses to learn how to use a new "calculator" to determine a more proper code.  After all, there will soon be over 70,000 of them.  Each more specific than the other, each more ridiculous.   There are five data-entry fields to click on that calculator, each another tiny, yet time-consuming decision to be made, just to determine a code.  No doubt teams of clever twenty-something computer programmers are overjoyed with their coding calculator and the way it pops up automatically on our screen when needed, then disappears.  So pretty.  So cool.  See how easy they've made it to complete that regulatory requirement?

And this does not begin to address the increasingly algorithmically-driven electronic medical record and procedures envisioned in the years ahead. As if all things can and must be perfectly defined and quantified in medicine.  No mistakes.  No judgment needed.  No need to type. Just close your eyes, click a few buttons, and follow the pathway.  Stop thinking. Just do it. Enter the data. Resistance is futile.

After all, it's about the money...

... and perfect physician cyborgs.

Feel that strap tightening?

-Wes

E-Flooded

I have been a way from blogging for a bit - tried to clear my head a bit with a vacation skiing - left the computer at home, disconnected (as best I could), and had the luxury of feeling the knees working less fluidly than they had before, but still had some fun for a brief 3-day stint.  It was nice to notice that there's a whole world out there - beautiful mountains, fresh air, nice friends.  All things considered, I am pretty lucky to have a stable job, appreciative patients, and a fulfilling career.

But it didn't take long after my return to work for me to feel flooded again.  Two days after returning to work, it was like I never left.  Perhaps it's like that for most busy folks, but somehow the world of health care delivery feels more frenetic than ever.  The in-basket messages,  the mountains of results, the re-scheduled patients on top of those already scheduled, the seemingly endless phone and e-mail messages, the late-night consults after a full day of procedures - all demanding time - it's bordering on crazy.  I have several nurse practitioners who assist, but the volume of electronic patient care that's happening now is overwhelming to even the most computer-savvy of us doctors.

And all of this communication is not compensated.  There are no "RVUs" for answering an e-mail.  There are no "RVUs" for speaking on the phone.  There are no "RVU's" for typing.  No "RVUs" for data entry and clicking a mouse.  Physician time means nothing to programmers and policy-makers.

It's a larger symptom, I think, of the new "efficiencies" built into the electronic medical record (EMR) that has become ubiquitous with the world of medicine today.  Information flies so fast and there's so much of it that it's getting almost impossible for doctors to keep up with the screen responsibilities, not to mention their care responsibilities.  The EMR is no longer just an EMR.  The EMR has morphed into  a scheduling agent, pharmacy, reminder pad, calculator, care pathway generator, instant-messaging service, a procedure orderer-by-proxy (and guideline) and a patient messaging portal that, aside from a 400-character limit, provides unprecedented  access to physician in-boxes and schedules. There are so many buttons that they no longer fit on a single screen and the "allergy" field no longer can be displayed as it's pushed out of the way by the name of the patient's insurer.  Add to this the constant and growing influx of patients (thanks to marketing pushes and programs to spur referrals), voluminous administrative meetings, and growing CME requirements, it's no wonder many of us feel flooded.  I work later than ever now thanks to these electronic "efficiencies," then find myself waking in the middle of the night wondering: Did I call Ms. Smith? Did I miss something? Did I put that order in? When am I going to do those result notes?

I think I'm suffering from post-traumatic electronic overload disorder (PTEOD).

Oh sure, we could hire another guy or gal to offload some of the work - maybe even hire a wasteful manpower-intensive scribe like those that work in some ERs that click for cash - but that really won't help stem the ongoing barrage of information that is now pummeling physicians and their care teams at an unprecedented rate.  Sadly, I don't see this trend changing anytime soon - the business case for the EMR is just too attractive for hospitals and payers.  Still, with the prospect of ICD-10 and it's 71,924 procedure codes and 69,823 diagnosis codes (that must be paired correctly lest doctors not be paid) just around the corner, I fear that physician stress, burnout and PTEOD will only increase as we are force-fed this diet of electronic overload without any reflection of what its doing to those who provide the care.

Ugh.  I need another vacation.

-Wes

Electronic Triage

Type a note.

Use a shortcut.

Cut and paste.

Order a test.

Review your tests.

Every result gets a note.

Release the result.

Ten new patient messages arrived.

See vacationing colleague’s results.

Did you see your patient’s been scheduled?

Verify you saw your patient was admitted.

Verify your order.

Sign your verbal order.

Telephone message.

E-mail message.

Operative note.

Code the note.

Bill the note.

Type instructions.

Order a procedure.

Print the summary

Update the problem list

Verify the medications – all of them – again

Update the medical history

Update the surgical history –right or left? When?

Family history?

Social history

Immunization history

Verify the allergies.

Make it meaningful.

Now repeat.

This is today’s electronic reality for doctors, and it’s getting worse every day.  Everything, it seems, must pass beneath a doctor's fingertips.

But there’s one thing skill that doctors have mastered when flooded that computer scientists and policy makers haven’t:

Triage.

And electronic triage is happening every day.

It has to.

After all, this is about life and death for everyone involved.

-Wes

When We Conflate Health Care With Medical Care

From Marilyn M. Singleton, M.D., J.D.:

“Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly, and applying all the wrong remedies.” -Groucho Marx

The politics of selling the Affordable Care Act (ACA) focuses on promising health and wellness. Somehow, having “coverage” is supposed to get you to a primary care doctor, who will keep you healthy. And if he doesn’t, he will be held accountable by not being paid.

The fact is that “healthcare reform” is not going to cure America’s health problems.

Physicians, think tanks, and politicians are pointing out a myriad of problems with ACA. But most of them miss the main point, which starts with calling it “healthcare reform.” The term, and the conversation about it, conflates health care and medical care. But they are not the same thing. Individuals are in charge of their own health care. Physicians provide medical care to those who become sick.

(Read the rest, especially the comments)

As I and others see the problems with "wellness initiatives" promoted by politicians and the insurance industry as cornerstones of our efforts to cut costs in our medical system, we should consider if institutional financial incentives will thwart any effort to achieve cost savings as physician productivity quotas are increasingly turned to as the driving force de rigueur for hospital profitability. Unfortunately, physicians are losing their ability to be stretched much further, especially as they struggle to keep up with the mushrooming number of inefficient certification and data-entry requirements, flooded e-mail in-boxes, and coding requirements necessary to continue practicing medicine in our new "reform" era. Then add the increasingly frequent hassles doctors are experiencing with their patients' insurance claim denials that go on for months. Medical care suffers as a result. Even our frontline force for quality medical care, nurses, are being stretched thin as many of their ranks are either let go or recruited as cleaning crews on top of their other patient care responsibilities.

Meanwhile, the insurance companies are recording record profits as Americans pay more and more into our system.

But, hey, thanks to the Electronic Medical Record and health care "reform" it sure is easy to order another colonoscopy in the name of "wellness" and "health care," right?

-Wes

How to Quell Physician Discontent with EMRs

How do you quell physician discontent with Electronic Medical Records (EMRs)?

Easy.

Have the leadership of your physician organization interview the National Coordinator for Health Information Technology, then make sure your physicians read the spin.  This is one of my favorite excerpts:

Q: Many physicians are not seeing the expected financial return on investment after EHR implementation. Why is that?

A: How you implement the technology has a lot to do with the results you achieve. (ed: Now, note how he dodges the question) But the bigger issue is how the compensation system is designed. If physicians are operating in a fee-for-service environment, then many of the gains of EHRs -- for instance, in quality, safety and patient engagement -- aren't reflected in revenue. Physicians are doing more work and delivering better care and service, but the added value is not reflected in the reimbursement. (ed: Okay, that's what we said: we're seeing lower pay, not higher, despite doing more and more meaningless data entry work with EHRs.  We are often not finding return on our investment with the additional work.  Why are you now addressing nebulous issues with physician payment reform? Could you stick with the question, please?)

We've been an advocate for making sure that when value is added, it's reflected in increased physician reimbursement whether it's through the patient-centered medical home (PCMH) setting (ed: Alas: no. It is impossible for the Coordinator to stick to the question.  Now we're on to Value-Based Purchasing. WTF?  Doctors aren't PURCHASING value, dammit, we're providing CARE!), value-based purchasing or part of an accountable care structure. That's where the ability to manage information -- not just for individual patients but for populations (ed: Remember dear doctor, it's not about you and your patient, EHRs are about the population manipulation!  Huh?)-- becomes an absolute necessity, because in those models, it's not a question of whether there's a return on investment with electronic health records. (ed: Yes, dear Coordinator, in case you forgot, this WAS the original question)  A physician can't function in those models without an EHR. (ed: Really?  Since when?)

If you can stomach more, go on over and read the whole thing.  (And consider leaving them a comment about how you really feel about this spin).

There.  You're a believer in in all things EMR now, right?

Doctor?

Doctor?

-Wes

Health Care Reform Three Years Later - An Insider's Assessment

It’s been three years since the Patient Protection and Accountable Care Act (PPACA) became law.  There have been widely divergent opinions published by journalists on the impact of the law for Americans: from a rose-colored account from the New York Times, to a not-so-peachy account published at Reason.com.  Few doctors have ventured into this discussion.

The Need for Health Care Cost Reform

I should start by saying that I am biased.  I grew up in the days of an idealized image of the physician –where doctors were still held in relatively high esteem by our society.  I had to think this way for I was joining the system.  Back then, like now for the younger doctors, medicine was a still considered a calling, not just a job.  The unspoken code was that it was the patient above all else: screw the establishment, screw hospital loyalty, screw the drug company – if they couldn’t help your patient, you’d take them elsewhere.  So hospitals courted doctors.  Drug companies courted doctors.  Insurance companies courted doctors.  But the truth be known, doctors weren’t the apple in everyone’s eye, patients were.  And doctors enjoyed the limelight – so much so, that a few in our ranks succumbed to the greed, too.  After all, like now, patients paid everyone’s bills.

But health care costs for patients became increasingly hard to cloak.  Insurance companies, in the business of making the expensive seem cheap, needed an exit strategy.  The new hospital buildings, multi-million dollar corporate earnings, drug innovations costing tens of thousands of dollars, and the aging population that was growing too quickly weighed heavily on the entire system’s sustainability.  Something had to be done.

The First Steps

So without belaboring the obvious: we created Health Care Reform as we know it.  Health Care Reform wasn’t just the PPACA, though, but rather a carefully orchestrated series of legislative achievements that laid the groundwork for payers to offload the costs of health care on to the only other entity that could pay these high costs: our government. 

The process (as we have seen) first involved an expensive, multibillion computer roll-out that was part of the American Recovery and Reinvestment Act.  These computer systems promised “cost savings” by “improving efficiencies” of care.  Information systems were sold as our salvation from cost excesses like $15 Tylenols.  Corporate America (and their political lobbyists) bought it and so did the government.  To keep doctors quiet, doctors were promised $44,000 a piece to install computers in their offices.  Little did they realize their payments from government to private offices were to be slashed forty percent in the same legislation and computers would be required to bill the government.  So, the $44,000 actually went to doctors’ new employers.  Doctors were thanked for their services with a new $700-dollar iPad and a treasure trove of Meaningful use regulatory benchmarks that slowed patient care rather than sped it.

Our New "Reform"

Next came the PPACA, our signature health care law.  The law was spun as a way to save health care costs while adding 34 million more uninsured patients to the system.  Pulling heart strings was much more palatable politically than the much needed reality of fiscal restraint.

But we should admit that our health care system has flaws when it comes to the uninsured.  To prove the health care reform’s benefits, the easy-to-sell low-risk coverage for young adults was given as a loss leader to the new health care law's Health Care Happy Meal.  This benefit was universally welcomed by all because it was needed.  Yeah, it cost a bit more to provide this insurance, but in the scheme of things, the cost of this health care was relatively cheap to provide.  It was (and remains) a win-win. But our attachment to this part of the law may be a clever way to buy us off.

Preventative services, provided for free, were also included in the PPACA.  But this is a problem because nothing is free in health care.  Proving preventative services for free perpetuates an expectation that everything will be free in health care and have no consequences.  After all, preventative services take time and time for care providers overloaded with more and more patients entering the system is our most precious commodity.   Others argue that catching problems early will save money but the proof that this makes a difference to health care costs is really just a delightful narrative.  In fact, even the annual physical’s benefit to our health care has been called into question – especially when we recognize its value to the system compared to the benefits derived for the patient.

And people have argued that the PPACA has already reduced costs.  While I am not an economist, I really can’t speak to this.  I am just a worker and observer.  These days I see four or five administrators where, just a few short years ago, we had one.  I see fewer nurses with less experience caring for more patients now.  I see bigger buildings but fewer patient beds as wards are consolidated.  I see hospital-system employers with hiring freezes that are laying off workers in anticipation of upcoming costs imposed by the new law. 

How's the Quality?

And then there’s the overall quality of care.  I can’t say I really see a difference from five years ago.  Sure, I see things being done faster by fewer.  I see computers moving information around like never before.  But is the care to our patients really better?  I see reams and reams of documentation made not for the patient’s benefit, but for bureaucrats and bean-counters more interested in our use of computers than our patients.  I see better communication between doctors improved with the EMR, but has this translated to better care delivery? Not always. And when it comes to quality, the New York Times editors cited the example that health care in America is cheaper because Medicare patients have fewer re-admissions since the PPACA was enacted.  But they also failed to note that hospitals receive financial incentives to reward this behavior.  They claim this is “better coordination of care” while ignoring the fact that patients are labeled with scarlet A’s and shunted to health care facilities that don’t "count" as re-admissions.  They also failed to mention the effects of the higher costs that patients see from their higher insurance premiums.  Cha-ching.

What's Ahead

In the end, health care reform is still about the money for the system rather than the real needs of most patients.  We are cutting costs to corporations by inflating our Health Care Hindenburg with cheaper hydrogen.  We have spun a narrative of providing more care for more people with less cost while ignoring the shear forces and telltale weather patterns of cost concerns that blow our way and threaten our ship's buoyancy.  

Some doctors have leapt from the ship.  More will certainly follow.  Others remain silent yet quietly discontented; they do their job as just job now, marking time with little incentive for doing more.  They have become the common workforce drone  increasingly asked to do more by those who go home at 5pm and have no liability for the care they provide.  More risk with less reward has been the mantra for care providers in health care reform.  The stress is growing for everyone.   Unfortunately, the doctors that leave will soon be back-filled by well-meaning young physicians with fewer hands-on hours of training that have been sculpted by an educational system dependent on tenured med-school professors complicit with our new progressive mindset. 

Health care reform is here, alright, doing what it's always done: spinning reform without real reform for three years (so far) and counting.

-Wes

Stuck

By now, the majority of America has noticed the new Windows 8 advertisement with young hipsters clicking iPad-like computer screens to a keyboard computer base: touch screens, magnetic attachments to computer bases, pretty colors with cool graphic user interfaces.  It all looks so cool, so hip.

But doctors should forget these things for the Electronic Medical Record of tomorrow.  After all, our biggest EMR, EPIC,  has been developed and tested with Windows XP or Windows 7 and it uses the MUMPS programming language.

I wonder, how long will the our next Windows platforms remain backwardly compatible to support our expensive EMRs?  How long will a non-graphic and cumbersome user interface MUMPS survive in tomorrow's graphical computer world?  More to the point: how much would updating to a more current operating system cost in the future?

Yeah, we're stuck with what we've got for a very long time.

-Wes

How Big Data's Fueling Complacency

"What's the most important finding on this chest x-ray?"

There he was, standing before 5 ICU residents, each peering at a chest film on displayed on the over-sized computer screen.

"Um, the pleural effusion?" whimpered a third-year resident.

"No!" barked the attending.

The others, standing dumbfounded in front of the computer display, searching for another finding but finding none, stood silently.

"Come on, folks!  Look!"

And try as they may, no one saw it.

"The name, folks, the name!" the attending said impatiently.

And there it was, a tiny reminder of whose x-ray it was, quietly lurking in tiny print in the upper right corner of the computer screen, unmagnified. 

But wait, the name was correct.  What the heck was he talking about?

Closer inspection showed another critical piece of information, totally lost on almost everyone standing there: the date of birth of the patient.  It was not the same as the patient being discussed. They were looking at the wrong patient's chest x-ray.  Never mind that their patient had a chest tube placed on the opposite side that wasn't shown on the displayed chest x-ray.  Yet they were already trying to make decisions for care.

***

I recently taught an EKG reading class and had a similar experience to the one above.  Since July, I've been teaching the basics of EKG reading at least once a month: rate, rhythm, axis, intervals - you know the drill, right?

But I (once again) asked about the axis of an EKG tracing we were discussing some six months later.  A room full of at least twenty residents sat quietly.  No one answered.

I kept my composure.  I prodded them gently, hoping to hear an answer yet none came.  Were they on call?  Distracted by their cell phones or pending work?  Am I THAT boring?

Still nothing.

So I reviewed how we determine EKG axis, and quickly, a few remembered the concept and gratefully, responded correctly.

But these experiences got me thinking about the effects Big Data is having on our residents today and its tendency to build complacency.  Why learn something if you're always spoon-fed it right?

Admittedly, our medical data explosion has prevented us from knowing everything there is to know about anatomy, physiology, pathology, treatment options and the like.  There is a role for access to Big Data.

But increasingly the data we feed our residents and medical schools is nothing but printed characters: x-ray reports, EKG interpretations, study results like "ejection fraction:" all limited to the 256 ASCII character set.  Residents no longer feel the need to look at the raw image and formulate their own opinion - they'll just look at the printed report.  They expect the data to be fed to them in printed format.  They expect the reading to be correct.  In a way, they're growing up expecting to be spoon fed just the black-and-white answers rather than the brilliant data provided by pictures.  Just "google it."

Never mind the computer says "atrial fibrillation" because the original EKG contains noise.

Such an "Big Data-entitled" approach to health care is extremely dangerous, especially if the data upon which decisions are based, are wrong.  Residents should never forget two things my father always told me:

"Garbage in, garbage out" and "expect what you inspect."

-Wes

Liability Reform: It's Coming

A collision is coming.

Scratch that.

The collision is here.

I'm not quite sure how to describe this, but I'll try.

Every day, I look at a computer screen for health care delivery with an increasing number of menu options.  I tried counting these menu options once and after scrolling through them, I never reached all of them after counting up to 275 items.

Yes, there are more than that, but suffice it to say, for most of us, that's enough to make my point.

Next, are the data points that confront my eyes every day.  Data points from all over and from all sorts of people.  Some whose names I recognize (even a few from me), but more importantly, many of whom I don't.  Hundreds and hundreds and hundreds of data points, streaming to me every single day.

What are these interrupters?

Many are orders for procedures.

Others are for results.

And phone calls.

And messages.

And patients recently admitted to other services for other procedures just so I know about them.

And patients to be scheduled for a procedure at a later date.

And blood draws.

And EKGs that have been ordered and not "signed."

And EKGs that have been read and not "signed."

And EKG results that were "signed" but returned to my "results" box just to remind me I "signed" them.

And ... well, just about anything.

All as part of the Great Medical Health Care Team plan.

But wait, who ordered all of these procedures, tests, results to be sent my way?

Some I did, but far more often, other people did.

Those other people are people who have been ordained capable of ordering those tests by other people.  Other people in our big, burgeoning health care system that extends over a larger an larger geographic area with more and more doctors than ever before.

And herein lies the challenge and the best hope for doctors' liability reform going forward: diffusion of their responsibility.

A few central planners whose grandiose health care narcissism have allowed unfettered access to physician responsibility for health care actions outside our real control in our new health care model so they can be paid.  Perhaps this was inevitable given the priority of providing care of so many more people without increasing doctors' ranks.    But as a result, doctors have unwittingly permitted programmers to send us all of these "notifications" so we must click on them so we can assume responsibility for their presence.  It's all part of the game:  get the doctor to click on it so it can be billed to payers.   Get the doctor to click on it so he or she can take the heat if there's a problem.

Licensed medical doctors continue to allow click after click after click, not to show we are using a computer "meaningfully" (as the programmers and political wonks would like you to believe), but really so we can assume responsibility for the results that ultimately come our way and for others to bill.

Need a flu shot?  Don't worry, it's auto-programmed computerized care pathway programmed by others on behalf of patients everywhere will happily send us a notification that the test was ordered and the results sent to the doctor so he or she can assume responsibility before he or she is even aware the test was ordered and resulted.  There it is: silently lying there in their inbox.

Click, doctor, click.

Forget about the egg allergy?  Oops.

Sorry, doc.

But increasingly, there's a little something that's happening as patients assume more of their health care bill: doctors are finding that they are effectively "responsible," even though we have no idea what things cost.  We are "responsible" for the patient's tests ordered, even though we didn't order them.  We are responsible for the results, because they come our way.  We are responsible for our "team," even though we had no responsibility for its selection.

The fanciful dream that doctors can be responsible for problems that arise can be completely blamed on doctors is a joke.  A very, very bad joke.

This is why liability reform will happen, whether the lawyers like it or not....

... not because doctors want it (even though they do), but because Big Business does.

-Wes

Patient Safety and the Ethics of EMR Implementation

“An experiment is ethical or not at its inception, it does not become ethical post hoc – ends do not justify means. There is no ethical distinction between ends and means.”

-- Henry K. Beecher, MD

“Ethics and Clinical Research,”

 New Engl J Med 274(24) June 16, 1966 pp 1354-1360.

"When everything is digitalized, all your records - your privacy is protected, but all your records on a digital form - that reduces medical errors. It means that nurses don't have to read the scrawl of doctors when they are trying to figure out what treatments to apply. That saves lives; that saves money; and it will still ensure privacy."

- President Barack Obama

The implementation of the electronic medical record (EMR) in American medicine gained a powerful foothold in medical care with the passage of the American Reinvestment and Recovery Act (ARRA) in 2009. With the passage of this act came the promise of improved efficiencies, safety and ultimately reduced cost delivery for health care. Also, some $18 billion dollars in financial incentives were offered to physicians to offset costs to deploy these systems nationwide. To assure adoption, if the systems were not implemented by 2015, doctors and care providers will suffer payment penalties from the government. For physicians who care for Medicare patients, there was no alternative than to deploy these systems.

In 2010 alone, the EMR market was pegged at $15.7 billion dollars, a cost that is ultimately passed to all Americans. In addition, despite all of the changes that health care reform has brought to date, people in some states continue to see their insurance premiums mushroom over 20% in 2013 from the preceding year. Simply put, patients are finding health care anything but “affordable.”

We should acknowledge that there might be cause, ethically, to deploy a technology that truly benefits patients at some cost. After all, you have to break a few eggs to make a good omelet. If interoperability of EMR systems between facilities were commonplace and clinical data were shared with ease while patient privacy was vigorously upheld flawlessly, the cost of these systems might be ethically justified.

But the promise of improved efficiencies to our health care system, improved patient safety and (especially) reduced cost for our health care system remain elusive. More importantly these goals remain unproven. In fact, examples that the opposite is occurring abounds as doctors struggle to enter ever-increasing amounts of information of no relevance to the patient’s presenting problem just to prove they’re using the EMR in a “meaningful” way, health data security breeches continue, errors are growing instead of shrinking, data-mining of patient information is occurring not just for patient care but for marketing purposes, and the direct costs of health care for patients continues to rise, not fall. Proponents of these systems will argue these issues are nothing more than “growing pains” of these novel systems.

So should we step back for a moment and ask ourselves if we are being ethical to patients with the deployment of this technology? Does the ends of presumed cost savings to our national health care system justify the deployment of poorly integrated, difficult-to-use systems? Are patients being subjected to new risks heretofore never considered with the adoption of this technology? Could a tiny programming error occur that negatively impacts not just one patient, but millions? If so, what are the safeguards in place to prevent catastrophic error? Who will be responsible? Who is the oversight body that assures the guiding principles of the Belmont Report (respect for persons, beneficence and justice) with respect to EMR deployment are followed? The Secretary of the Department of Health and Human Services or a more nebulous body like Congress?

If we accept that the benefits of the EMR are at least uncertain to patients in terms of risk and cost, we should demand they be studied before deploying them. The guiding medical ethics tenets would demand nothing less. So, would not such study qualify as human research? After all, we should remember that the United States and other countries have a precedent of human research programs performed by government agencies that were usually highly secretive, and in many cases information about them was not released until many years after the studies had been performed.

From a sentinel paper in 1966 by Henry J. Beecher, MD on Ethics in Research:

"I should like to affirm that American medicine is sound, and most progress in it soundly attained. There is, however, a reason for concern in certain areas, and I believe the type of activities to be mentioned will do great harm to medicine unless soon corrected. It will certainly be charged that a mention of these matters does a disservice to medicine, but not one so great, I believe, as a continuation of the practices cited.

Experimentation in man takes place is several areas: in self-experimentation; in patient volunteers and normal subjects; in therapy; and in the different areas of experimentation on a patient not for his benefit but for that, at least in theory, of patients in general."

While Beecher’s paper was addressing ethical research errors in general, his words are oddly prescient for EMR development. Ethical errors, as he pointed out, “are increasing not only in numbers but in variety.” He points to one of the biggest drivers of ethical conflict: money.

“Of transcendent importance is the enormous and continuing increasing in available dollars for research, as shown below:

Money Available for Research Each Year

Year	Massachusetts General Hospital	National Institutes of Health
1945	$500,000	$701,800
1955	2,222,816	36,063,200
1965	8,384,342	436,600,000

These data, rough as they are, illustrate vast opportunities and concomitantly expanded responsibilities.

Taking into account the sound and increasing emphasis of recent years that experimentation in man must precede general application of new procedures in therapy, plus the great sums of money available, there is reason to fear that these requirements and resources may be greater than the supply of responsible investigators.”

The need for “responsible investigators” remains significant; funding for all of the National institute of Health in 2011 was $142.5 billion dollars. Annually, EMR companies have received the equivalent of 11% of the entire NIH annual research budget from US citizens without having to prove their safety or value to patients.

Again, from Beecher’s paper:

“The ethical approach to experimentation in man has several components; two are more important than others, the first being informed consent. The difficulty of obtaining this is discussed in detail. But it is absolutely essential to strive for it for moral, sociologic, and legal reasons. The statement that consent has been obtained has little meaning unless the subject or his guardian is capable of understanding what is to be undertaken and unless all hazards are clear. If these are not known this, too, shall be stated. In such a situation the subject at least knows that he is to be a participant in an experiment. Secondly, there is the more reliable safeguard provided by the presence of an intelligent, informed, conscientious, compassionate, responsible investigator.”

Because EMR deployments are cloaked in intellectual property, non-disclosure and restrictive hospital employment agreements, doctors are often prohibited from voicing specific concerns about an EMR system publicly. In addition, by adopting EMR systems as cornerstones of the American health care system, Congress, the President and the ARRA side-stepped patients’ informed consent regarding the short-comings of these systems, advertising only their desired benefits instead. Furthermore, rather than Congress turning to “conscientious, compassionate, responsible investigators,” they turned to lobbyists when deciding to fund the deployment of unproven EMR systems. As a result, doctors were relegated to becoming nothing more than stewards of data entry subject to new, ever-evolving documentation requirements as these systems evolve for cost-saving benefits and care "efficiencies."

Patients and doctors alike understand the need for improved efficiencies and value in our era of exploding health care costs. We must strive to find a solution to our health care cost crisis that is transparent, cost-effective and ethical. Without such an effort, our health care system will collapse. Only recently has the Office of the National Coordinator of Health Information Technology recognized the problem and opened their Health IT Patient Safety Action and Surveillance Plan for public comment. This plan asks the EMR companies and interested stakeholders to develop their own methods to assure patient safety and reporting systems – a move that approaches the same ethical standards as equivalent of asking the foxes to watch the henhouse. Nonetheless, we should acknowledge their efforts.

But we should be cautious of EMR systems as we move forward. After all, these clinical systems have not been subjected to the same cost-benefit and ethical scrutiny as other clinical tools we use in health care. The scrutiny of EMRs should be no different than that found with pharmaceutical or medical device research where Institutional Research Board approval and proof of no conflict of interest is demanded. Why should clinical EMR systems be any different?

Given the profit motives and market consolidation occurring amongst the purveyors of these EMR systems and the potential for lethal EMR errors both from software and human interface issues, doctors and patients must especially question the ethics of the movement to deploy untested, novel technology on our patient population under restrictive covenants. As part of informed consent, patients should have full understanding of how and where their clinical data are used, including when it will be used for direct-marketing campaigns, prioritizing care delivery, or for research. Patients should be able to opt out of the use of their clinical data for these or any other purpose if desired, without restricting payment for care. Finally, physician and patient concerns about EMR systems should be allowed to be vetted publicly and without threat of professional or personal reprisal or the withholding of payments for care rendered, especially and particularly if these disclosures are performed in the best interest of patient care.

To do otherwise is unethical for our patients and the public at large.

-Wes

Meaningful Abuse

Sometimes, the money made for pursuing bureaucratic pursuits is not worth the time required to fulfill them.  This is becoming especially true for "meaningful use" criteria that have been developed by the government to penalize doctors if they don't use the Electronic Medical Record in a "meaningful" way.  The roll-out of punitive measures to "encourage" doctors use of EMRs began with varying "stages" of required compliance and threatens to implode upon itself:

For Stage 1, physicians have to meet a total of 15 core (required) measures, select five measures of their choice from a menu set of ten, and also meet six clinical quality measures. For Stage 2, physicians are required to meet more measures: 17 core measures, an additional three measures of their choice from a menu set of six measures, and starting in 2014, meet nine clinical quality measures. The Health IT Policy Committee’s proposal for Stage 3 would nearly double the number of measures physicians would have to meet for each patient in order to avoid meaningful use financial penalties. Failing to meet just one measure by  one percent would make a physician ineligible for incentives and face the same financial penalties during the penalty phase as those physicians who make no effort to adopt EHRs.

You read that correctly.  If you do all the clicky computer things the government wants with each patient visit, you will not have time to care for your patients.  So never mind if you don't have a clue what all these "stages" of computer use actually mean because I can help you:

With the proposed Stage 3 Meaningful Use criteria coming down the pike, you will be penalized for using the Electronic Medical Record because you don't use it well enough no matter how hard you try.  After all, patient care is not the priority, computers are. 

Any questions?

(Yeah, it's hard to make this stuff up.)

-Wes

Reference: AMA Letter to the Office of the National Coordinator for Health Information Technology

Cost Savings from EMRs: A Path to Salvation

The Electronic Medical Record (EMR)'s promised contribution to health care cost savings got a second look recently, and the results were poor at best.  But what I found interesting was the "second look" was from the same organization that did the first look: the corporately-funded, non-profit think-tank called the RAND Corporation.  From their second and more recent report:

"A team of RAND Corporation researchers projected in 2005 that rapid adoption of health information technology (IT) could save the United States more than $81 billion annually. Seven years later the empirical data on the technology’s impact on health care efficiency and safety are mixed, and annual health care expenditures in the United States have grown by $800 billion."

Who would have thought that such a prestigious organization like the RAND Corportation could have made such a teeny, tiny multi-billion dollar mistake? After all, their 2005 study was funded entirely by several of the major EMR manufacturers who have reaped billions in revenue on EMR sales since.  Is there any wonder that now the same RAND Corporation felt that the EMRs the lack of cost savings is really the end-users' fault?

"In our view, the disappointing performance of health IT to date can be largely attributed to several factors: sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and the failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT."

What a shallow assessment.  There is no mention of the cost of these systems, their maintenance, lack of interoperability, poor user-interfaces, and in many cases, lack of graphics support.  Even more ironic, there was no consideration that someone might actually figure out a way to efficienctly skirt the government's arcaine documenttion requirements for reimbursement that would permit MORE health care spending.  No, those assessments would have been too obvious.  Instead, the Rand Corporation tells us that there were no cost savings with the EMRs is because doctor- and hosptial-customers didn't re-engineered their care processes or "adopt" substandard first-generation systems.

Give me a break.  At least the Congressional Budget Office saw through the Rand Corporation's ruse in their scathing report (pdf) from 2008.

Even so, at this point it doesn't matter.  Doctors and patients alike understand that there was too much corporate money involved and too many politicians' campaigns happily funded as the Stimulus Bill that implemented the EMR nationwide was crafted.  As a consequence, little will be done about either of the Rand Corporation's erroneous and over-zealous EMR cost-saving predictions now.  Whether we love it or hate it, the Electronic Medical Record is here to stay.   Government incentives have made it so and are still slated to grow.  More to the point, our lack-of-cost-savings epiphany came so late that most of our newly-graduated doctors have never used a paper chart and likely never will.

So now that the whole EMR implementation and cost charade has been exposed (and a blind eye permanently cast), what should doctors do now?

First, doctors must demand value for the money wasted spent on the multitude of EMR systems out there.   No where would that value be more evident than if interoperability standards were required within two years, especially when different health care systems use the same EMR system.  This is especially so with EPIC Systems, the largest EMR nationwide that is thought to contain patient records, at last estimate, some 40% of the nation's hospitalized patients.  Right now, this minute, most of the major medical centers in Chicago use EPIC.  There is simply no excuse any longer that doctors from one major medical institution shouldn't be able to view clinical records at another institution, especially when they use the same software.  Silo-ed patient data is not a value-driven proposition for the patient but rather a profit-driven proposition for hospitals.  As such, transferability of patient data between hospitals and health care systems should become one of the highest "quality standards" for hospitals to achieve and (perhaps) stiff payment penalties applied if this goal is not met. Patients (and the doctors trying to care for them) deserve nothing less.

Second, open avenues of communicating concerns about EMR functionality and safety should be mandated  and not restricted to conversations moderated behind secured web-based firewalls hosted by twenty-something computer nerds with no clinical experience.  Social media involvement by companies, be it by way of blogs, Twitter, LinkedIn, or Facebook, should be the norm.  Such open discussions encourages constructive, transparent and understandable transmission of tips, tricks, and (most importantly) needed improvements as EMRs mature.  After all, there's nothing better than a screenshot or picture(s) (devoid of patient information, of course) published for all to see to make a point and affect change. A grass-roots critique of EMR systems by doctors is long overdue.

Third, EMRs should not try to be all-encompassing.  They should stick with what they know.  Do not try to be a graphical user interface when you write in MUMPS, for instance. It's embarrassing.  If you can't do graphics, pictures or difficult multi-layercalendars, then dove-tail with someone who can.   To do otherwise creates unfamiliar non-standardized interfaces that invite treatment errors and inefficiencies rather then correcting them.

Today the sad reality is this: EMR interactions consume more of the physician's time than direct patient care.   EMR companies should realize that as long as doctors are challenged by data entry and the ever-increasing documentation and verification requirements to maintain their livelihood, they will speak out on the new challenges posed by the the EMR publically.  Companies that embrace and respond effectively to constructive criticism openly and honestly are much more likely to be viewed favorably by the health care marketplace and (who knows?) might even help to save a buck some day.

-Wes

The Costs of Not-so-Shared Decision Making

This week's New England Journal of Medicine contains a perspective piece by Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. entitled "Shared Decision Making to Improve Care and Reduce Costs." The original paragraph of the piece sets the tone:

"A sleeper provision of the Affordable Care Act (ACA) encourages greater use of shared decision making in health care. For many health situations in which there's not one clearly superior course of treatment, shared decision making can ensure that medical care better aligns with patients' preferences and values. One way to implement this approach is by using patient decision aids — written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options; each option's outcomes, including benefits and possible side effects; the health care team's skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients' values.

However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making. We believe that the Centers for Medicare and Medicaid Services (CMS) should begin certifying and implementing patient decision aids, aiming to achieve three important goals: promote an ideal approach to clinician–patient decision making, improve the quality of medical decisions, and reduce costs."

What a nice, lovely, fuzzy bunny.  Who couldn't want such "shared" decisions in complex medical care?  Especially nice simple teaching aids for Medicare's top 20 procedures printed at the "8th grade level" that are "brief?"

Doctors, don't you know that this will become simply another box to check on your EMR for Medicare reimbursement? 

And yet the benefits of cost savings that these "shared" decision making tools' will have on health care are assumed, especially when deployed nationwide, despite what the authors claim.  Note that the 2011 Cochrane Collaborative review of the 86 studies they reference said nothing about cost savings.

Doctors know this and so do the authors.

Why else would the authors require a cudgel to impose their "shared" decision making benefit if other real life clinical doctors fail to follow along?

"Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics."

Ms. Lee and Dr. Emanuel, in their zeal to impose their Progressive mindset upon America's physicians have forgotten several important tenets of health care delivery:

• First, decisions made in medicine are each unique to a patient's constellation of medical problems, socioeconomic and cultural background, age, gender, religious beliefs, etc.  In other words: decisions are made in concert with an individual's situation, and not based on the government's desire (necessarily) for cost savings (even if it is couched in euphemisms such as "shared decision making").


• Second, actual cost information (both out-of-pocket and real health care system costs) for patients and doctors will remain shrouded  in secrecy since payers rely on obfuscation of actual cost information to extract their portion of fees before patients receive any value for their dollar.  Also, other similar pay-for-performance measures have already uniformly flopped at demonstrating cost savings.  Then imagine for a moment if the cudgel for shared decision making is imposed.  The potential for a 10-20% Medicare physician fee cut on top of a 30% Sustainable Growth Rate cut that is likely to reappear in 2014 will be untenable for US physicians. 


• Third and very importantly, the ACA legislation has created a whole new "institute" of salaried individuals within government called the Patient-Centered Outcomes Research Institute (PCORI) to develop the authors' soon-to-be-mandated decision aid materials while another branch of government already exists to produce such education aids called the Agency for Healthcare Research and Quality (AHRQ).  Wouldn't our health care system benefit far greater from cost savings by not duplicating services already performed by another government agency? How much, exactly, will the PCORI cost us?


• Fourth, the push to re-invigorate the mass-production of physicians via three-year medical school curricula while simultaneously failing to increase residency slots assures poorer trained, inexperienced doctor-patient discussions about complicated medical issues, not better ones. Shared does not mean better.


• Finally, liability risks remain for doctors caught in these unenviable mandates that fail to recognize the individual complexities of an individual patient's care.  Until doctors sense a modicum of effort for liability reform, they will continue to offer care that exposes both themselves and their patient's to the path of lowest legal risk, irrespective of what teaching aids they give to patients.

Doctors and the AMA should demand transparency in the cost of creating and funding the PCORI and its shared decision making materials, yet another layer in the runaway middleman health care behemoth emerging as the front lines of health care delivery are systematically decimated. 

If that doesn' t matter to all of us, then share away.

-Wes

The Currency of the Future

From this morning's Wall Street Journal:

Medtronic says federal rules prohibit giving Ms. Hubbard's data to anyone but her doctor and hospital. "Our customers are physicians and hospitals," said Elizabeth Hoff, general manager of Medtronic's data business. Medtronic would need regulatory approval to give patients the data, she said. It hasn't sought approval because "we don't have this massive demand."

. . .

Some legal experts say the 1996 U.S. law governing patient access to their health files—HIPAA, or the Health Insurance Portability and Accountability Act—hasn't kept up with technology. The law gives patients the right to access information held by doctors and hospitals. However, the raw data gathered by an implant isn't held by a doctor or a hospital: Typically it goes directly to the device maker, which provides a summary report to the doctor. Because of this, the raw data falls outside the scope of HIPAA's patient-access requirements. In addition, Medtronic said, business agreements with doctors and hospitals restrict it to relaying information only to them.

"Is the device itself a depository for medical records?" said Paul C. Zei, a cardiologist at Stanford University Medical Center with a patient, Hugo Campos, who wants the same access to his cardiac-device data as the doctor gets. "Or is it part of the patient, and an extension of vital signs that we download into a medical chart?"

Gee.  Someone saw this coming years ago. 

But as patients pay for more and more of their health care, companies better remember who's really their customer.  Furthermore. patients should have access rights to all of their medical information, irrespective of where it resides.

-Wes

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.

-Wes

Skynet: When the EMR Isn't Enough

It was supposed to be an initative to implement the Electronic Medical Record. 

Instead, it is quickly morphing to Skynet. 

Like a black hole, everything goes in to Skynet now.  Nothing escapes its gravitational pull. 

Schedules, supply chains, staffing grids, calendars, medicines, pharmacies, insurance plans, pay for performance initiatives, quality measures, door-to-balloon times, billing codes, procedure codes, everything. 

Ever-expanding. Spreading. Consuming. 

All left unchecked.

The office computer was used to be Skynet's reach, but it quickly expanded to the home computer and the cell phone, provided you're willing to have the cell phone's memory swiped clean if you leave Skynet's grasp.  Personal schedules, too, have fallen victim to Skynet as everyone's whereabouts are tracked for all to see in the name of staffing and operating efficiency.  

And this week, "personalized medicine" moved a step closer as the complete DNA material of more than 1,000 people from 14 population groups in Europe, Africa, East Asia and the Americas were sequenced so they may serve as a standard reference against which doctors could one day compare a patient's genome profile, even during a routine checkup.

Yes, more fodder for Skynet.

Eerie.

Kind of makes you wonder when we'll be terminated, doesn't it?

-Wes

Schedules

It started as big day in the lab: six cases. Actually, my partner and I were eventually able to split the load over two labs.

But I screwed up.

I took too long putting in a device - WAY too long.  Four hours too long.  Since it was the first case of the day, it backed everything up. People had to work very late - some even had to dip into overtime.

But  I was impressed that no one said a thing.  In fact, everyone that I worked with was incredibly supportive.  After it was over, one of my nurse practitioners even bought me a salad on her own dime before she laid into me with a ton of pending questions about outpatients and the new consults upstairs.

Why?

Because my colleagues know about schedules in medicine.  They know that some things we do can be incredibly challenging due to anatomic variables that aren't always there in the normal individual.  They know that sometimes we work on sick folks, young and old, who really have no other options - that a particular procedure might be their one best and only shot at getting better.  They know that many other times, the cases go faster.  They know that these things can happen.  So they remain professional and make a their calls home to say they'll be late.

Schedules, I'm finding, are getting more complicated in our consolidated new health care world.  So much so that administrators are turning to computers to help.  And who can blame them?  Different cases, different time allotments, different hospitals, different doctors, different equipment needs, different drive times between facilities, different days for clinic, different insurance, different staffing needs.  It's simply getting too complicated for any one person to keep it all straight in their head. 

But computers rely on logic.  Computers rely on criteria on which to make decisions - they must have an estimated procedure time to go with every procedure.  Computers don't incorporate variations in physician skill level, technique, or a person's individual anatomy into their scheduling algorithms. Computers don't know about a son's baseball game.   Computers don't factor in the frustrations of traffic.

I never like making that call home when I am running late.  I never like to hear the sighs, the disappointment, to learn what I'm missing.  But I have also learned that it is far worse not to make the call.  My family's schedule and psyche demands it.

But as the day's work is algorithmically sliced across increasingly geographically-dispersed larger and larger health care systems with schedules more and more compressed, I wonder if computers will ever be able to explain to our families why we keep running late.

-Wes

Why the Electronic Medical Record Needs to Be Viewed as a Medical Device

In our rush to establish a national electronic medical record (EMR) system as part of the American Recovery and Reinvestment Act of 2009, powerful silos of independent EMR systems have sprung up nationwide.  While most systems are being developed responsibly, like the Wild, Wild West, many have been developed without an objective eye toward quality and the potential  harm they may be causing our patients.

As most readers of this blog are aware, since 2005 the medical device industry in which I work has had widely publicized instances of patient deaths splashed all over the New York Times and other mainstream media outlets from defibrillator malfunctions that resulted in a just a few patient deaths.  The backlash in response to these deaths was significant: device registries were developed, software improvements to devices created, and billions of dollars in legal fees and damages paid to patients and their families on the path to improvement.  In addition, we also learned about the limits of corporate responsibility for these deaths thanks to legal precedent established by the Reigel vs. Medtronic case.

Should Electronic Medical Records Be Considered Medical Devices?

This week I received a medical record from a large academic medical center somewhere in the United States (the details are unimportant) that has one of these new pioneering EMR systems manufactured by $13 billion-dollar company, Cerner Corporation.  Now before I go on a rant about Cerner's EMR system, I should preface my remarks to say that I have never personally used Cerner's system.  But I am a doctor who received a note composed on Cerner's system and what I saw was one of the better examples of how EMR's are contributing to misinformation and confusion when health care is delivered.   

I received a copy of an internal medicine consult that was performed on a patient at this outside hospital.  I have extracted the "medications" portion of the internist's note exactly as it was displayed in the note below (although the list extended over more than one page, so I joined the list together as one figure). Needless to say, I was terrified at what the system had listed as the patient's medications:




Med List (Page 1) - Click to enlarge

 

Med List (Page 2) - Click to enlarge


In this example, we see multitudes of medications listed more than once.  We see drugs of similar classes (antihistamines, beta blockers) on the same list.  We see warfarin, one of our most dangerous drugs dispensed, without a dose included.  We see what seems to be outpatient meds listed with inpatient meds, I'm not sure.  Honestly, we really have no idea what medications are actually being taken from this list.  And yet this list of medications is listed by the EMR as the patient's "Active Medications."

What the heck have we created?

Certainly, any capable physician who cares for patients would describe this medication list as worthless.  So why is it in there?  (Don't get me wrong, the fact that any doctor would allow such crap to be displayed in his or her medical note by using an EMR shortcut to enter them uncorrected is beyond me.  Certainly, we as doctors must accept a big portion of the responsibility for this). 

But when EMR developers and their hospital administration customers purchase software capable of spewing forth completely useless AND potentially lethal information about our patients that is then transmitted far and wide, (not to mention to local direct caregivers) doctors have an obligation to speak up.

These kinds of documentation problems are the EMR's Achilles' heel.  But beyond this, EMR software updates are routinely deployed without real-world real-life testing.  Ever.  And yet, like patients with a defibrillator who die outside the hospital before a root cause of a defibrillator defect can be discovered, I acknowledge that it is  incredibly difficult to prove that the death of an individual was caused by an EMR software problem.

And yet, we must.

So how will we measure problems with EMRs?  It seems industry representatives would rather not address these concerns.  We should ask ourselves, is anyone thinking about this?

Right now, the prevailing belief is that the electronic medical record might be one of the most important medical devices doctors have at our disposal to care for patients.  I tend to agree.  But it's potential to do harm is also enormous if it is not used responsibly and accurately.  After all, as the above example shows, the potential to introduce unintended yet potentially lethal errors into patient care is huge.  More importantly, since nearly every person in the United States will soon have their medical data housed within these systems, the number of people that could be adversely affected by these systems is much larger than what we've seen with our recent defibrillator malfunctions. 

Perhaps, like the ICD registry, we should try to to develop an EMR registry of adverse patient outcomes caused by these software systems.  That way, every independent EMR company can learn from the other's mistakes.  Because, guess what ...

... like other man-made medical devices, EMR's are not perfect either.

-Wes

Meaningful Abuse

As health care reform rumbles along, it has become increasingly clear that electronic health records (EHRs) are here to stay. I dare say, most of us are relatively happy that the change has come: notes are legible, information moves quickly, communication channels between doctor and patient are improved, and work flows streamlined.

Well, not always.

Take the example of the work flow required to process a simple office-based EKG:

• Enter an order for an EKG
• perform the EKG
• A doctor edits, interprets and signs the computer-interpreted paper EKG
• EKG and it's edits are loaded on the central EKG server
• the results are electronically "signed" by the doctor on central EKG server to it can get posted as "final" on the EHR
• A notice appears in the doctor's EHR results in-box notifying him that a new EKG result is available for review.
• Ideally, the doctor attaches a "result note" explaining the results to the patient and the result forwarded to the patient electronically.
• Except many patients don't use a computer
• So the patient is called and another hand-typed electronic telephone note added to the patient's electronic health record to document that the patient was informed of the result.

All of this time, energy, effort, for a single EKG.

Now, multiple that by ten EKG's, three echos, two chest-xrays, and a partridge in a pear tree that gets ordered on our patients each day and you've just created "result bloat" for doctors.

When a single test result must be "resulted" three or more times by the attending physician because of constraints of conjoined information technologies, not only do we demonstrate meaningful use of our electronic medical records, but we also demonstrate meaningful abuse of our doctors' and support staffs' precious time.

First we saw "note bloat."

Now we're seeing "result bloat."

Washington, are you listening?

-Wes