(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.
Showing posts with label electronic medical record. Show all posts
Showing posts with label electronic medical record. Show all posts
Sunday, August 30, 2015
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.
(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.
Saturday, December 13, 2014
Electronic Medical Record and the Threat of Physician Skill Fade
As I watch the business world's fascination with the electronic medical record (EMR) and all of the Big Data that it accumulates, I see more and more processes codified and treatment pathways carefully honed. Only one small thing remains until the computer can tell doctors how to behave based on the developed algorithms: to turn free text in the patient chart into easily-definable binary pushbutton selections, so now, this is being done.
The theory, of course, is for computers to understand doctor's free text and medical decision making. By making a myriad of discrete data entry choices, we are told, recommendations for care can be made based (of course) on the best "evidence-based" guidelines the world has to offer. Data can then be quantified. Physician selections, easily followed and tracked. "Quality measures" (as defined by guidelines) "simply" quantified. This is our latest "New Vision" for health care. And as our nation hurries to implement electronic health care delivery through government mandates and regulations to assure "meaningful use" of computers, the gushing assurances of improved care spews forth from many who stand to profit from the system.
Imagine: doctors won't have to think. They'll just click the buttons and be in compliance. Stay between the lines and you're quality scores will be perfect,. Your care will be impeccable in the eyes of the developer; efficient, timely, thorough.
What could go wrong? After all, the guesswork is gone. The knowledge base clearly defined. The treatment of the disease efficiently rendered. And now, everything can be perfectly quantified.
I should acknowledge that there are clearly efficiencies gained by such a tact. But there is also a downside that really hasn't been seriously considered by most: we risk developing physician skill-fade. This, in turn, introduces a new unforseen risks to our patients since practice freedom is restricted as each algorithm demands conformity rather than innovation, improvisation, and any semblance of risk taking on the patient's behalf. After all, the computer code is optimized for its creator, the health care Iron Triangle, not the patient.
I was struck by a recent article by Nicholas Carr in the Wall Street Journal entitled, "Automation Makes Us Dumb." In it, Mr. Carr describes the benefits and challenges that automation has produced and mentions the EMR:
In fact, who needs doctors at all if care is reduced to point and click? While our new breed of physicians have never known medicine without a computer, will all of their study and preparation to become clinicians at the bedside be rendered moot as these young doctors find themselves little more than data entry clerks? How will we keep them clinically skilled? Homogenized mannequins programmed to respond to regimented scenarios?
Creating disease-directed algorithms might be efficient at treating a medical problem but this does not really treat the patient. With the infinitely variable human condition, might we be fooling ourselves with a false promise of unwavering algorithmic simplicity? Since patients rarely have one health problem but many, do these simplified treatment pathways consider the effects of other confounding ailments? Do our programmers and engineers care?
This myopic vision for medicine is where we are currently heading. Scores of centrally-created computer mandates continue to restrict the freedom of developers to move where computer-aided treatment advances need to go. As we create our linear and static algorithms that are unyielding to nuance or change (and created during a tiny snapshot of history), we should remember these limitations since physicians' freedom to act in the best interest of their patients is lost if doctors become complacent and also financially incentivized to do so. Such restriction might lower costs, but at a risk to patient care.
Realizing computers in medicine are here to stay, I can only hope that in the years ahead as computerized health records develop, a new era of computerized algorithms will evolve that adapt to any number of physician-directed exceptions and exclusions appropriately. Computers and EMRs must inform the physician rather than mandate, instruct rather than impugn, encourage adaptation rather than thwart it, and always facilitate rather than inhibit patient care. This way physician skill-fade will be minimized and a more efficient care delivery that is patient-centered rather than industry-centered can thrive.
-Wes
The theory, of course, is for computers to understand doctor's free text and medical decision making. By making a myriad of discrete data entry choices, we are told, recommendations for care can be made based (of course) on the best "evidence-based" guidelines the world has to offer. Data can then be quantified. Physician selections, easily followed and tracked. "Quality measures" (as defined by guidelines) "simply" quantified. This is our latest "New Vision" for health care. And as our nation hurries to implement electronic health care delivery through government mandates and regulations to assure "meaningful use" of computers, the gushing assurances of improved care spews forth from many who stand to profit from the system.
Imagine: doctors won't have to think. They'll just click the buttons and be in compliance. Stay between the lines and you're quality scores will be perfect,. Your care will be impeccable in the eyes of the developer; efficient, timely, thorough.
What could go wrong? After all, the guesswork is gone. The knowledge base clearly defined. The treatment of the disease efficiently rendered. And now, everything can be perfectly quantified.
I should acknowledge that there are clearly efficiencies gained by such a tact. But there is also a downside that really hasn't been seriously considered by most: we risk developing physician skill-fade. This, in turn, introduces a new unforseen risks to our patients since practice freedom is restricted as each algorithm demands conformity rather than innovation, improvisation, and any semblance of risk taking on the patient's behalf. After all, the computer code is optimized for its creator, the health care Iron Triangle, not the patient.
I was struck by a recent article by Nicholas Carr in the Wall Street Journal entitled, "Automation Makes Us Dumb." In it, Mr. Carr describes the benefits and challenges that automation has produced and mentions the EMR:
In a study conducted in 2007-08 in upstate New York, SUNY Albany professor Timothy Hoff interviewed more than 75 primary-care physicians who had adopted computerized systems. The doctors felt that the software was impoverishing their understanding of patients, diminishing their “ability to make informed decisions around diagnosis and treatment.”But what is the real issue? While the development of treatment rubrics can improve health care efficiency and productivity for their creators, I fear rote implementation of these algorithms will also also atrophy a physician's clinical and reasoning skills. Binary decisions buttons might facilitate note creation and data gathering, but they discourage the use of physical examination (remember that?) and the evaluation of nuance or clinical exceptions. With creation of our current iteration of care pathways and guidelines, there is now little need for exceptional thinkers, only adequate thinkers. What would skill fade look like in medicine? And at what point do the exceptional experienced physicians start becoming vulnerable to skill fade?
Harvard Medical School professor Beth Lown, in a 2012 journal article written with her student Dayron Rodriquez, warned that when doctors become “screen-driven,” following a computer’s prompts rather than “the patient’s narrative thread,” their thinking can become constricted. In the worst cases, they may miss important diagnostic signals.
The risk isn’t just theoretical. In a recent paper published in the journal Diagnosis, three medical researchers—including Hardeep Singh, director of the health policy, quality and informatics program at the Veterans Administration Medical Center in Houston—examined the misdiagnosis of Thomas Eric Duncan, the first person to die of Ebola in the U.S., at Texas Health Presbyterian Hospital Dallas. They argue that the digital templates used by the hospital’s clinicians to record patient information probably helped to induce a kind of tunnel vision. “These highly constrained tools,” the researchers write, “are optimized for data capture but at the expense of sacrificing their utility for appropriate triage and diagnosis, leading users to miss the forest for the trees.” Medical software, they write, is no “replacement for basic history-taking, examination skills, and critical thinking.”
In fact, who needs doctors at all if care is reduced to point and click? While our new breed of physicians have never known medicine without a computer, will all of their study and preparation to become clinicians at the bedside be rendered moot as these young doctors find themselves little more than data entry clerks? How will we keep them clinically skilled? Homogenized mannequins programmed to respond to regimented scenarios?
Creating disease-directed algorithms might be efficient at treating a medical problem but this does not really treat the patient. With the infinitely variable human condition, might we be fooling ourselves with a false promise of unwavering algorithmic simplicity? Since patients rarely have one health problem but many, do these simplified treatment pathways consider the effects of other confounding ailments? Do our programmers and engineers care?
This myopic vision for medicine is where we are currently heading. Scores of centrally-created computer mandates continue to restrict the freedom of developers to move where computer-aided treatment advances need to go. As we create our linear and static algorithms that are unyielding to nuance or change (and created during a tiny snapshot of history), we should remember these limitations since physicians' freedom to act in the best interest of their patients is lost if doctors become complacent and also financially incentivized to do so. Such restriction might lower costs, but at a risk to patient care.
Realizing computers in medicine are here to stay, I can only hope that in the years ahead as computerized health records develop, a new era of computerized algorithms will evolve that adapt to any number of physician-directed exceptions and exclusions appropriately. Computers and EMRs must inform the physician rather than mandate, instruct rather than impugn, encourage adaptation rather than thwart it, and always facilitate rather than inhibit patient care. This way physician skill-fade will be minimized and a more efficient care delivery that is patient-centered rather than industry-centered can thrive.
-Wes
Friday, September 05, 2014
Cybernetic 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
Tuesday, August 12, 2014
Data Plan Health Care Shows Promise
CHICAGO - Citing mounting health care costs, electronic note bloat, and concerns with the quality and quality of Big Data, IBM, Apple, and EPIC Systems recently announced a new initiative to totally revamp US health care by offering health care services by data plan. The health care initiative was recently discovered in a little known section of the Patient Protection and Affordable Care Act (ACA) that changed portions of the U.S. Tax Code.
Under the new system, the brainchild of prominent Chicago physician-turned-health care entrepreneur Henry Throckmorton, MD, patients will purchase an initial 250 megabytes of data space on the EMR for all their health needs for $250 per month. “It’s cheaper than most current cell phone service," Throckmorton explained. "When patients exceed their data allotment, health care ceases until patients purchase an additional data storage plan." Expansion data plans come in Bronze (250 M Bytes), Silver (500 Mbytes), Gold (5 G Byte), and Platinum (10 GB) storage increments.
Rollover plans for family members are also offered for those nearing the end of life.
“Health care systems that promise to limit the use of macros, dot phrases and cut-and-paste tactices have a real competetive advantage over competitors insensitive to the patient's data needs!” Throckmorton explained. "This system finally puts health care incentives in the right place.”
But Roger Wilco, spokesperson for America’s Health Insurance Plans (AHIP), the national trade association representing the health insurance industry, seemed less enthusiastic. "This is preposterous! Who do these flowery internet types think they are? Don't they realize there are advantages to more middle men in health care? How are we supposed to get our cut of the money?"
Dr. I.P. Knightly of Urocare Health System in Beaverton, New York, seemed less concerned about the middlemen and appreciated the improvements he's seen in patient care: “Because I document everything on the EMR, including phone calls, results and work schedules, patient are less likely to call so I get a good night’s sleep!”
Nursing and medical students seem torn, however. While some see benefits to shorter notes, some like Tim Allen, MD, a hard-working fourth-year medical student from Roanoke, VA, sees other challenges “I’m still trying to understand ortho notes that no longer contain the critical information fields like the patient’s full name, VIP status, research status, and a complete review of systems. How's a guy supposed to understand what ‘Silt @ t/s/s/sp/dp’ means?”
Market analyst Rebecca Solomon of Lock, Stock and Barrel Equity Partners noted "Apple, IBM and EPIC are quickly gaining market share from more conventional insurance policies. The concept has also resonated with the Department of Health and Human Services because of the cost savings seen from fewer data-hungry imaging studies being ordered."
Mobile partnerships with AT&T, Verizon, and T-mobile are planned in the next fiscal year.
* * *
-Wes
P.S.: If you thought this press release might be real, even for a second, consider why.
Sunday, August 10, 2014
From the Mouths of Babes
"Dad, you have the nicest patients!"
She was right, of course. Daughters that you bring to work with you to shadow for a day can bring you back to what's important in medicine. In fact, seeing medicine through fresh eyes is helpful, especially when we forget to look up from our work-a-day lives.
It had been over ten years since I had my first "Bring Your Daugher to Work" experience. Her first time she wore scrubs they were bigger than she was. She always remembered that day.
There probably won't be too many more times we'll share such an experience together. Like most young college kids she's growing her own life now, trying to decide what to do.
"Why not shadow me and my nurse practitioner for a day to see what think? I have a light day, you could really see what we do first-hand!"
Much to my surprise, she agreed. And so we spent the entire day together once more.
She saw everything I did but this time with a more critical eye. She saw everything my nurse practitioner did, too. Just in case. She witnessed the miracle of anesthesia, a strangeness of the "time-out," then the jolt of a cardioversion. She saw the smile of the patient after it was all over. She saw the real discourse that occurs between colleagues that are used to working with each other. She saw the computer. She saw the EKG. She saw the family discussion afterward. Everything.
Perhaps most touching was the moment we walked into a long-time patient's room - a fellow doctor - and there he was, lying in bed with his ankles too swollen with his wife, daughter, and granddaughters by his side. His eyes, while a bit sunken, were beaming when he saw me.
"I'd like to introduce you you my family!" he exclaimed. And one by one he introduced me to his lovely wife, daughter, and granddaughters who had all come to spend some time with him. Of course, I couldn't resist, and similarly gushed, "I'd like to introduce you to a member of my family, too!" I proudly introducing my daughter to him and the rest of his extended family. His grandaughters were slightly younger than my daughter - just starting to think about college. My daughter, now a veteran of the college experience, offered some words of encouragement to them. They graciously nodded. I couldn't help but marvel how therapeutic that interaction was for both of us - doctor and patient - a way to bring our lives a bit closer, our understanding, more meaningful. Medicine is like that sometimes: one minute you're there to help the patient then you realize how much, in their grace, they help you.
I pretended not to think about this as I checked his defibrillator. "Working fine," I told him. He glanced at me and said "thank you" in a way I'll never forget: non-verbally with his eyes, as if to say, "I know how you're feeling."
We left the room and returned to the nurse's station - or maybe it should be called the "Computer Terminal Station," since doctors, pharmacists, physical therapists were all playing a game of musical chairs waiting for a terminal to open. More typing and staring at screens, more phone messages, documentation, lab checks, more typing, all clicked as fast as possible. Finally, after seeing more patients and typing more notes, we had a debriefing. Relaxed and looking forward to heading home, I asked her: "So what did you think?"
"You know, Dad, it was wonderful. Your patients are all so nice. But..."
There was a moment of hesitation in her voice, a concern, as she wrestled with how to break the news to me slowly; I could tell she didn't want to disappoint me.
"What is it?" I asked.
"... there's just so much typing!"
-Wes
She was right, of course. Daughters that you bring to work with you to shadow for a day can bring you back to what's important in medicine. In fact, seeing medicine through fresh eyes is helpful, especially when we forget to look up from our work-a-day lives.
It had been over ten years since I had my first "Bring Your Daugher to Work" experience. Her first time she wore scrubs they were bigger than she was. She always remembered that day.There probably won't be too many more times we'll share such an experience together. Like most young college kids she's growing her own life now, trying to decide what to do.
"Why not shadow me and my nurse practitioner for a day to see what think? I have a light day, you could really see what we do first-hand!"
Much to my surprise, she agreed. And so we spent the entire day together once more.
She saw everything I did but this time with a more critical eye. She saw everything my nurse practitioner did, too. Just in case. She witnessed the miracle of anesthesia, a strangeness of the "time-out," then the jolt of a cardioversion. She saw the smile of the patient after it was all over. She saw the real discourse that occurs between colleagues that are used to working with each other. She saw the computer. She saw the EKG. She saw the family discussion afterward. Everything.
Perhaps most touching was the moment we walked into a long-time patient's room - a fellow doctor - and there he was, lying in bed with his ankles too swollen with his wife, daughter, and granddaughters by his side. His eyes, while a bit sunken, were beaming when he saw me.
"I'd like to introduce you you my family!" he exclaimed. And one by one he introduced me to his lovely wife, daughter, and granddaughters who had all come to spend some time with him. Of course, I couldn't resist, and similarly gushed, "I'd like to introduce you to a member of my family, too!" I proudly introducing my daughter to him and the rest of his extended family. His grandaughters were slightly younger than my daughter - just starting to think about college. My daughter, now a veteran of the college experience, offered some words of encouragement to them. They graciously nodded. I couldn't help but marvel how therapeutic that interaction was for both of us - doctor and patient - a way to bring our lives a bit closer, our understanding, more meaningful. Medicine is like that sometimes: one minute you're there to help the patient then you realize how much, in their grace, they help you.
I pretended not to think about this as I checked his defibrillator. "Working fine," I told him. He glanced at me and said "thank you" in a way I'll never forget: non-verbally with his eyes, as if to say, "I know how you're feeling."
 |
| Our "selfie" that day |
We left the room and returned to the nurse's station - or maybe it should be called the "Computer Terminal Station," since doctors, pharmacists, physical therapists were all playing a game of musical chairs waiting for a terminal to open. More typing and staring at screens, more phone messages, documentation, lab checks, more typing, all clicked as fast as possible. Finally, after seeing more patients and typing more notes, we had a debriefing. Relaxed and looking forward to heading home, I asked her: "So what did you think?"
"You know, Dad, it was wonderful. Your patients are all so nice. But..."
There was a moment of hesitation in her voice, a concern, as she wrestled with how to break the news to me slowly; I could tell she didn't want to disappoint me.
"What is it?" I asked.
"... there's just so much typing!"
-Wes
Sunday, June 01, 2014
Clicks Unchecked
"Where did that menu item come from?" I recently thought. "Come to think of it, where did the Allergy field go? What's that? I have to enter an 'Order' for a consent now? Whatever happened to speaking with the patient?"
Such are the myriad of thoughts the EMR engenders lately. So ridiculous. So time-consuming. Death my a hundred thousand clicks. It's like my fingertips are on high continuous suction. Pretty soon I'll have to click the "Excuse Me" or "Pause" button so I can use the bathroom.
Seriously. In medicine, everything is entered on the computer now. Everything. Not just notes and orders, but schedules, message boards, meeting notifications, billing check-boxes that must be paired with diagnosis check boxes. If it isn't clicked, it didn't happen. Every time a new "idea" for process improvement that springs forth is codified for the computer. And guess who's the data entry clerk?
It's gotten so bad we now must scroll to display all the menu options. Even filtering the notes to ones you wrote is dreadfully slow. Unfiltering them worse still. Precious seconds of patient care time are repeatedly wasted.
It was bad before, but it's getting worse. The foxes are minding the hen house of patient safety and doctor overload. Not that computers aren't wonderful at some things - they are - but to suggest, even for a moment, that they can fix what ails health care in America is ludicrous; to suggest they aren't silently inflicting their own patient care comprise even crazier.
Yet the drumbeat of unending support for computers, simulation, data manipulation continues. Profit does this.
The data clerks are growing weary.
And patients are noticing.
-Wes
Such are the myriad of thoughts the EMR engenders lately. So ridiculous. So time-consuming. Death my a hundred thousand clicks. It's like my fingertips are on high continuous suction. Pretty soon I'll have to click the "Excuse Me" or "Pause" button so I can use the bathroom.
Seriously. In medicine, everything is entered on the computer now. Everything. Not just notes and orders, but schedules, message boards, meeting notifications, billing check-boxes that must be paired with diagnosis check boxes. If it isn't clicked, it didn't happen. Every time a new "idea" for process improvement that springs forth is codified for the computer. And guess who's the data entry clerk?
It's gotten so bad we now must scroll to display all the menu options. Even filtering the notes to ones you wrote is dreadfully slow. Unfiltering them worse still. Precious seconds of patient care time are repeatedly wasted.
It was bad before, but it's getting worse. The foxes are minding the hen house of patient safety and doctor overload. Not that computers aren't wonderful at some things - they are - but to suggest, even for a moment, that they can fix what ails health care in America is ludicrous; to suggest they aren't silently inflicting their own patient care comprise even crazier.
Yet the drumbeat of unending support for computers, simulation, data manipulation continues. Profit does this.
The data clerks are growing weary.
And patients are noticing.
-Wes
Sunday, March 09, 2014
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
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
Friday, January 17, 2014
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.
It has to.
After all, this is about life and death for everyone
involved.
-Wes
-Wes
Wednesday, July 31, 2013
Images of Change: Charting
 |
| Image courtesy Kathy Neider, MD, Staff Physician, Baptist Health |
"I'm sitting where my credenza used to be, stacked high with charts. I figured if I was going to be in my office till late at night finishing electronic charting, it might as well be in a comfortable place."
Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link). -Wes
Saturday, July 13, 2013
The Clash of Cultures
"It looks like you've done very well, Mr. Smith..."
"Thank you, doctor."
He left the patient's room and ambled back to the nurses station, legs tired and ankles somewhat swollen. It had been a long case and now he just had to type his note, send an email message, and review his schedule for the following day. He sat down at the computer and logged in. That's when he looked up briefly and saw them.
They looked so young. Their newly-pressed white coats accentuated the faint glow of the computer screens on their perfect skin. They looked like thoroughbreds, while he the old horse put to pasture, if they had noticed. But they were each staring intently at the electronic screen arranged along the desk countertops, one with his back to the other two. Occasionally the one would turn to ask the other two a question, then return with a blank stare to the screen before him. The new residents had arrived.
"So different," he thought. There they are, seated before a computer looking more like telephone operators rather than doctors. "What were they thinking?" he wondered silently, then pondered how things had changed.
For now he realized that they didn't have to know where the blood or microbiology laboratories were. They didn't have to search for an x-ray. Instead, they had to find which button to click. This day, this moment, was probably their dream come true. For it was the day they had waited and worked so hard for, the day they became a working doctor. Underneath the electronic facade, they were probably excited, eager, wanting to do a good job: excitement and anxiety, all rolled up into one.
But somehow, it was different. The new doctors rarely looked at each other as they stared vacantly into their computer screens. It was as though they were transfixed by medical porn. It looked as though they were being bred into an interchangeable electronic medical documentation team, not a cohesive, personal one equipped with interpersonal skills. After all, they really didn't have to see or listen to each other any more. They could send each other an e-mail, text messages, or chose to stay isolated, listening to the rapid-fire clicking taking place next to them. Emotionally and physically, they could be miles apart or seated together, it really didn't matter any more. It was so efficient, so neat, that their organized orientation to electronic dehumanization required very little movement, very little patient contact.
But young doctors, he realized, were meeting their patients like they've always met new friends on Facebook: electronically first. Was this better? He wasn't sure. Would the initial impressions garnered from the chart skew their ability to look independently and objectively at their patient? Will they be capable of accurate empathy? Will a patient's undocumented concerns be missed? Will new doctors forget to use the subtle signs and symptoms brought forth by the physical exam to head off disaster or just wait for the test results to return before reacting instead? Will they see enough, smell enough, do enough, sweat enough, to learn enough?
He wondered.
But they were young. They could learn. They would learn. They'd adapt.
And they could type faster.
Perhaps. Maybe. We'll see. "I can only hope," he thought, realizing he wasn't getting any younger.
He turned his gaze back to his own screen and clicked the icons slowly, the way he had done hundred of times before, filling his note with voluminous immaterial drivel the government required, then added a single line: "Doing well. Home today." So meaningful, he silently quipped, meaningful indeed.
He rose to say goodbye to the unit clerk, who smiled as she peeled her eyes from her iPhone, "Goodnight, doctor."
"Take care of the new guys, okay?" as he pointed to the people behind her with the new white coats.
"You bet," she said, not turning to see them. Her eyes reset to to her iPhone screen instead.
-Wes
"Thank you, doctor."
He left the patient's room and ambled back to the nurses station, legs tired and ankles somewhat swollen. It had been a long case and now he just had to type his note, send an email message, and review his schedule for the following day. He sat down at the computer and logged in. That's when he looked up briefly and saw them.
They looked so young. Their newly-pressed white coats accentuated the faint glow of the computer screens on their perfect skin. They looked like thoroughbreds, while he the old horse put to pasture, if they had noticed. But they were each staring intently at the electronic screen arranged along the desk countertops, one with his back to the other two. Occasionally the one would turn to ask the other two a question, then return with a blank stare to the screen before him. The new residents had arrived.
"So different," he thought. There they are, seated before a computer looking more like telephone operators rather than doctors. "What were they thinking?" he wondered silently, then pondered how things had changed.
For now he realized that they didn't have to know where the blood or microbiology laboratories were. They didn't have to search for an x-ray. Instead, they had to find which button to click. This day, this moment, was probably their dream come true. For it was the day they had waited and worked so hard for, the day they became a working doctor. Underneath the electronic facade, they were probably excited, eager, wanting to do a good job: excitement and anxiety, all rolled up into one.
But somehow, it was different. The new doctors rarely looked at each other as they stared vacantly into their computer screens. It was as though they were transfixed by medical porn. It looked as though they were being bred into an interchangeable electronic medical documentation team, not a cohesive, personal one equipped with interpersonal skills. After all, they really didn't have to see or listen to each other any more. They could send each other an e-mail, text messages, or chose to stay isolated, listening to the rapid-fire clicking taking place next to them. Emotionally and physically, they could be miles apart or seated together, it really didn't matter any more. It was so efficient, so neat, that their organized orientation to electronic dehumanization required very little movement, very little patient contact.
But young doctors, he realized, were meeting their patients like they've always met new friends on Facebook: electronically first. Was this better? He wasn't sure. Would the initial impressions garnered from the chart skew their ability to look independently and objectively at their patient? Will they be capable of accurate empathy? Will a patient's undocumented concerns be missed? Will new doctors forget to use the subtle signs and symptoms brought forth by the physical exam to head off disaster or just wait for the test results to return before reacting instead? Will they see enough, smell enough, do enough, sweat enough, to learn enough?
He wondered.
But they were young. They could learn. They would learn. They'd adapt.
And they could type faster.
Perhaps. Maybe. We'll see. "I can only hope," he thought, realizing he wasn't getting any younger.
He turned his gaze back to his own screen and clicked the icons slowly, the way he had done hundred of times before, filling his note with voluminous immaterial drivel the government required, then added a single line: "Doing well. Home today." So meaningful, he silently quipped, meaningful indeed.
He rose to say goodbye to the unit clerk, who smiled as she peeled her eyes from her iPhone, "Goodnight, doctor."
"Take care of the new guys, okay?" as he pointed to the people behind her with the new white coats.
"You bet," she said, not turning to see them. Her eyes reset to to her iPhone screen instead.
-Wes
Tuesday, March 26, 2013
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 First Steps
Our New "Reform"
-Wes
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.
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 inAmerica 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.
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
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.
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.
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
Wednesday, March 20, 2013
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
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
Sunday, February 17, 2013
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
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
Sunday, January 27, 2013
By the Numbers
Diagnosis codes: numbers.
Procedure codes: numbers.
Speadsheets of one's "productivity:" numbers.
Spreadsheets of RVU's: numbers.
Spreadsheets of total office visits: numbers.
Speadsheets of new office visits: numbers.
Spreadsheets of complications: numbers.
Spreadsheets of new codes on top of old codes: nothing more than more numbers.
Then numbers converted to numbers.
Speadsheets of revenue: numbers.
Spreadsheets of accounts receivables: numbers.
Spreadsheets of patient satisfaction scores: numbers.
Number of Patient calls: numbers.
Number of Staff messages: numbers.
Miles traveled: numbers.
Continuing Medical Education credits: numbers.
National Practitioner Identifier: numbers.
Letters typed, converted to bytes, then bits, then zeros and ones.
Fingers numb, eyes searching. Unable to find a number...he stopped and looked up.
He wondered.
Where are the codes for color, for smell, for sound, for touch, for tears, for fear, for terror, for pain, for exhaustion, for laughter, for teaching, for listening, for learning, for love, for patience, for tenderness, or for grace?
"They paved paradise and put up a parking lot," he thought as he marveled at the revery of medicine's latest myopic trend:
cold, raw, unemotional, unassailable, yet remarkably error-prone,
numbers.
-Wes
Procedure codes: numbers.
Speadsheets of one's "productivity:" numbers.
Spreadsheets of RVU's: numbers.
Spreadsheets of total office visits: numbers.
Speadsheets of new office visits: numbers.
Spreadsheets of complications: numbers.
Spreadsheets of new codes on top of old codes: nothing more than more numbers.
Then numbers converted to numbers.
Speadsheets of revenue: numbers.
Spreadsheets of accounts receivables: numbers.
Spreadsheets of patient satisfaction scores: numbers.
Number of Patient calls: numbers.
Number of Staff messages: numbers.
Miles traveled: numbers.
Continuing Medical Education credits: numbers.
National Practitioner Identifier: numbers.
Letters typed, converted to bytes, then bits, then zeros and ones.
Fingers numb, eyes searching. Unable to find a number...he stopped and looked up.
He wondered.
Where are the codes for color, for smell, for sound, for touch, for tears, for fear, for terror, for pain, for exhaustion, for laughter, for teaching, for listening, for learning, for love, for patience, for tenderness, or for grace?
"They paved paradise and put up a parking lot," he thought as he marveled at the revery of medicine's latest myopic trend:
cold, raw, unemotional, unassailable, yet remarkably error-prone,
numbers.
-Wes
Sunday, January 20, 2013
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
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."
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.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.
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."
“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
Friday, January 18, 2013
If EMRs Were Research, Would They Pass IRB Muster?
Imagine for a moment that you were a principal investigator who wanted to study your independently-developed electronic medical record system for clinical use. You have spent billions developing your system, housed it in a high-security fortress with its own power grid, power backup-system, multiple fiber-optic T3 lines that dovetail with large communications contractors. Your experimental system is outfitted with the latest and greatest software innovations to chart patient encounters, transmit lab data and post results, interact with other vendor software manufacturers, and bill patients for procedures performed while collecting huge volumes of patient data in data repositories. You want to prove the EMRs ability to safely care for patients, lower health care costs, and prevent errors. Your hypothesis is that your EMR system does all of these things.
But to gain approval for your study, you must bring it before an Investigational Review Board (IRB) for approval before you can begin your research project. For those unfamiliar, an IRB is a committee that has been formally designated to approve, monitor, and review biomedical and behavioral research involving humans. They often conduct some form of risk-benefit analysis in an attempt to determine whether or not research should be done. The number one priority of IRBs is to protect human subjects from physical or psychological harm. In the United States, the Food and Drug Administration (FDA) and Department of Health and Human Services (specifically Office for Human Research Protections) regulations have empowered IRBs to approve, require modifications in planned research prior to approval, or disapprove research. IRBs are responsible for critical oversight functions for research conducted on human subjects that are 'scientific', 'ethical', and 'regulatory'.
Interestingly, billions and billions of dollars ride on your study being shown true. You are convinced, I mean convinced, that your EMR will do all the beneficial things your hypothesize with little to no downside. After all, you have strong political and financial backers that agree with you. You have deployed your experimental system to over 40% of the entire US population in preparation for your study. It's time to start, you say.
I wonder, if the readers of this blog were members of the IRB and this study was presented to you, what safeguards would you insist upon to protect patients? Would the study, as proposed, pass muster?
-Wes
But to gain approval for your study, you must bring it before an Investigational Review Board (IRB) for approval before you can begin your research project. For those unfamiliar, an IRB is a committee that has been formally designated to approve, monitor, and review biomedical and behavioral research involving humans. They often conduct some form of risk-benefit analysis in an attempt to determine whether or not research should be done. The number one priority of IRBs is to protect human subjects from physical or psychological harm. In the United States, the Food and Drug Administration (FDA) and Department of Health and Human Services (specifically Office for Human Research Protections) regulations have empowered IRBs to approve, require modifications in planned research prior to approval, or disapprove research. IRBs are responsible for critical oversight functions for research conducted on human subjects that are 'scientific', 'ethical', and 'regulatory'.
Interestingly, billions and billions of dollars ride on your study being shown true. You are convinced, I mean convinced, that your EMR will do all the beneficial things your hypothesize with little to no downside. After all, you have strong political and financial backers that agree with you. You have deployed your experimental system to over 40% of the entire US population in preparation for your study. It's time to start, you say.
I wonder, if the readers of this blog were members of the IRB and this study was presented to you, what safeguards would you insist upon to protect patients? Would the study, as proposed, pass muster?
-Wes
Wednesday, January 16, 2013
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:
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
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
Thursday, November 29, 2012
The Currency of the Future
From this morning's Wall Street Journal:
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
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
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.
-Wes
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
Thursday, November 01, 2012
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
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
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