Over-Diagnosis - Ascension of the Luddites

Technology in medicine has dramatically altered the landscape of care through its ability to contribute to the diagnosis of complicated medical problems.  But as technology improves, results that containing more complex data require nuanced interpretation.  While the sensitivity of tests has increased, those tests that cast wider nets often bring specificity into question.

Luddites were 19th- century English textile artisans who protested against newly developed labor-saving machinery from 1811-1817.  During the Industrial Revolution, artisans were threatened to be replace with less-skilled, low-wage laborers, leaving them without work.  The modern day Luddites are concerned about the cost and possible harm (radiation, more tests, more surgeries) that more high-tech tests can generate.

Underneath apprehensions about over-diagnosis lies the foundational issue of controlling costs as the technology exponentially improves.  A justifiable concern is the ordering of tests when results will not alter or impact the treatment or outcome of the problem.  In a vast majority of cases, providers place such orders in the showdown of a malpractice threat that dwells just beneath the surface, subconsciously informing most every clinical interaction.

The term over-diagnosis attributes too much psychological power to the physician, who might thereby assume knowing just how much data the patient needs to know.  In my home, my wife would want to know every detail and decide for herself, rightly or wrongly, whether she's been subject to over-diagnosis or the findings represent important data.

Emergency physicians generally have a highly trained level of diagnostic accuracy.  The concept of over-diagnosis is therefore fundamentally contrary to how ED docs intuitively function, especially since emergency medicine rapidly accepts and adopts new technology into treatment guideline.  The question becomes how much technology should the provider unleash on the patient.  The Luddites lost in the 19th century and will again lose in modern times.

A problem always arises when ordering newer tests in  the first place and learning to live with the results if ordered.  This is so at least until some experience is gained.  A new name should be created to become the buzz word for the concept, perhaps--Intelligent Ordering.  Optimally, one would be judged not only on the amount of resources used, but also outcome. 

Technology is advancing rapidly.  The concern over radiation will be severely diminished with the new scanners.  Medicine has evolved realty since I began in 1975.  Back then, changes took decades to settle in.  The new time frame for gaining traction for a test is 3-5 years.  We should embrace technology, but use it judiciously.

Did Sisyphus Work Out?

In Greek mythology, Sisyphus was a king of Ephyra punished for chronic deceitfulness.  He was would roll an immense boulder up a hill, only to watch it roll back down.  He was compelled to repeat this action forever.

Sounds like real-life.  3 fitness tests you should be able to pass article recently posted on Fox News,  asked readers to evaluate their physical health.  Here are the 3 simple tests to judge your health:

1. Waist size less than half your height (Failed that one)
2. Hold the plank position (strict push-up form) for 2 minutes (Failed that one)
3. Get to and up from a seated position with minimal use of hands and knees.  Score is 1-10 with losing a point for every use of hand or knee.  Score less than 3 was associated with a five time higher likelihood of dying versus people who got an 8 or above.  (Got a 7)  This was not a controlled double blind study.

Your physical health is a great predictor of your mental health and your work performance.  In the blog I wrote last February, Prolonging Your Career, I discussed how adding the constant stretching program Restorative Yoga, my flexibility has gone from 5% to 60%.  My blood pressure has lowered and I have lost a little weight.

Some find that gyms open 24-hours are beneficial, and heading there after a shift beneficial.  Especially when a shift has been stressful, a good workout can relieve tension and enable one to return home with some of the tension productively disbursed. 

Being a health care provider is a stressful job, so it is imperative that you take care of the shell surrounding the brain by working the core surrounding your waistline with a consistent strength and conditioning program such as Yoga, Pilates, TRX, Personal Training, etc.  Working out is a Sisyphus-like task, but does have its rewards.

EHR Blues...Co-authored by Dr. Donald Kamens

Upon reading even just a few of the thousands of review articles on the Electronic Health Record- EHR, it is quite reasonable to conclude that most clinicians would prefer paper.  Why?  The details are many, but the overall impression one gets is that providers do not really see value in performing tasks that are predominately secretarial especially when their already overstretched time could be more effectively spent on actual clinical matters, like communicating with patients and staff, decision making, care consideration, and real-time research.

Unfortunately, though, an unanticipated secondary tier of clerical tasks accompanies most newly deployed EHR modules, and these wind up, of course, in the physician's to do box.  Particularly within modules for order entry (CPOE) and chart documentation, such overhead generates excessive demands on provider attention and effectiveness.

At many institutions, un-navigable interfaces trigger
frustrations and administrators react by throwing more staff at the problem.  Therefore, we now see an increasing number of extra personnel (medical assistants, physician extenders and scribes) carrying laptops, tablets, and smartphones, but not bandages and IV fluids.  Because there is a tendency to sweep EHR deployment shortcomings under the rug, they tend to live beyond conscious recognition, and instead within some hypothetical virtual promise, in a time soon to come.

Thus, while hires may -  on the surface - seem to be made to help provide better overall care, the intrinsic, systemic demands placed on a mouse & keyboard ED staff, by far exceed those placed on a pen & paper staff.  Indeed, logic says that a staff whose workflow and process has improved above that of pre-EHR times, needs correspondingly fewer personnel.  Right?  However, inadequacies in EHR design and performance, and the  necessity of complex workarounds to accomplish simple basic tasks, have instead added to the workload, and have done so beneath the surface, in an almost unconscious plane of operation.

So, since costs tend to reside in an unconscious plane, the ED department will likely not recognize the source of the issues for what they are: generated by the very presence of the EHR, itself.  Moreover, no EHR vendor intends to clue your department in on this.  After a while, one becomes accustomed to extra medical staff, as they become embedded features of the landscape.  Has anyone said that the cost of medical care has gone down since the advent of EHRs?  No Way!  Rather, it is continuous, in the other direction- up, always up.  Hence, a few minutes with pencil and calculator can show that the cost of (staff) adoption to meet EHR practical use will soon exceed the billions in incentives directly paid to physicians for EHRs adoption through meaningful use.  In the end, therefore and sadly, a loss.

This is not to say there is no value in EHRs.  There is indeed some, and there is certainly promise.  Yet, to put the rate of progress directly on the backs of practicing physicians makes no sense whatsoever, especially when the big-picture for the US, includes major systemic health-care overhaul.

 

In areas such as data collection, decision-making, and legibility, a (very) few EHRs hold promise to make things better, in comparison with care currently able to be provided with just pen and paper.  That's a problem, because it trades current quality of health care for future promises that do not have guaranteed benefits.  Doing so isn't necessary.  Yet with quality EHR offerings slim, and pressure to choose high, physicians are correspondingly impaired in their ability to discern what's best for them within what is available.  As a result, most initially attracted by meaningful use monies have found it simply not worth the effort.  Of course, administrators and those who oversee healthcare from a governmental level will think differently.  Nevertheless - and this is a key point - most persons responsible for selecting clinical systems, are themselves not providers, have never directly provided medical care, and never will provide medical care with their own, medically trained, hands.  That's like turning over car design to a group that rides bikes to work every day.

 

Indeed, after all the effort made with meaningful use, and all the billions spent, there is minimal substantive evidence that quality has improved or that efficiencies have been achieved.  Meaningful use activities may look good from a statistician's viewpoint, but very few of the processes that necessarily tag-along with EHR implementation have practical function in the real world.  For example, handing a patient a paper copy of a CCD*, together with 12-pages of discharge instructions, serves little purpose.  Not surprisingly, many clinicians simply do not even know what a CCD even is - nor should they need to know - any more than we need to know the underlying formatted structure of the receipts we sign in restaurants and retail merchants.  Each format is different from the next, and even though the data elements are identical, we commonly just scan for the bottom-line, whether paying at a restaurant, or understanding what actually happened with a patient.  In the case of a patient "represented" by a CCD, chances for successful electronic transmission and succinct presentation of the "bottom-line", are marginal, if at all present.

Over the last few years,, the rush to implement EHRs in time to get meaningful use money has forced hospitals to make decisions based too fully on financial considerations, instead of on finding practical, real, solutions to improve care.  This has led to user (physician) angst and chronic end-user (patient) uncertainty.

 

Institutions have also tried, not-surprisingly, to solve long-term efficiency issues with computer-based solutions that don't address underlying issues.  For example, an electronic bed board may say that room 222 is ready to be cleaned, but if the system cannot assist housekeeping personnel to get there in real-time, the patient destined for that room - once cleaned - is still taking up a bed in the ED.

 

Turning providers into "data jockeys" has created cumbersome workarounds (some quite creative) to offset what was lost from the inherent benefit, simplicity, and efficiency of paper and pen. 

 

But, there is hope.  Perhaps the media will one day say about meaningful use, what Elwood said to Jake in the Blues Brothers (1980), "It wasn't a lie, it was just bulls**t."  With costs increasing and reimbursements under constant scrutiny, there will be in the future a huge push to have an end-user friendly electronic health record with all the fancy artificial intelligence features to save money and eliminate inefficiencies.  Let's hope it really succeeds the next time around.

* The CCD (Continuity of Care Document) is one of several electronic templates proposed by standards organizations to enable interoperability (electronic sharing and reuse) of medical information.  The CCD (as well the CDR, the CDA-R2-CDA, and others) has been constructed to standardize and facilitate rapid transmission of a summary of the patient’s recent course and current condition, readily showing vital signs, family history, plan of care, and so on.  The CCD, however, is not considered the best formulation by everyone. There have been multiple CCD releases over the past decade, all the while trying to establish a standard format into which an EHR can automatically input a summary of the medical history, and output the CCD as an HTML-type document that can be sent to, and read by, other EHRs.  Hence, again in theory, any CCD should be electronically transmissible between differently constructed EHRs, installed by different vendors, and operating cross distances.  Achieving this would be something like building standard fuel pumps for automobiles, so that no matter what the engine happened to be, fuel-pump replacement on a Mercedes would be the identical to that on a Ford. 

Wikipedia says:  “The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. Its primary use case is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient.^{[1  ]    “}

 

The Lucey Disease

My associate has recently come down with a new syndrome related to extensive interaction with the Electronic Health Record.The symptoms are an overwhelming desire to shout expletives, when distracted the data he is inputting is now located in the wrong place!

When reviewing the condition, it is characterized by calm demeanor that explodes into frustration, anxiety, stress and the use of inappropriate language in the clinical setting.

The individual is confused and frustrated by the less than simplistic navigation, complex interfaces, and inability to remember the last known "work around".

This diagnosis could not be found in the Diagnostic and Statistical Manual of Mental Disorders (DSM).  It is used or relied upon by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system and policy makers.

However, treatment has not been well studied but reassurance, back-rubs, and electroshock convulsive therapy seem to ameliorate the symptoms.

The Harsh Realities of Aging in the Workplace

One of the most difficult subjects for any medical practice is dealing with under-performance.  Viewed through its various lenses- including productivity, patient, staff and owner (hospital, etc.) satisfaction- under-performance is multifaceted and difficult to effectively engage from all perspectives.  An additional distortion is added when normal aging is thrown into the mix.

"You are as old as you feel" is a great saying.  However, if a healthcare provider does not have enough personal insight into his/her own actual competencies, normal workplace deterioration can, over time, lead to major interpersonal, financial, and professional problems.

Honesty with coworkers, employees, partners, and spouses is an idealized goal.  But such honesty- fraught with misinterpretation and potential conflicts- is rate, and seldom materializes.

Many solutions have been proposed, but a good resolution always requires creating a plan in advance to address performance and performance failures.  such a plan not only helps identify problems as they arise, but also gives concrete steps to support affected individuals, while anticipating potential snags that may appear over time.  Optimally, taking such steps as a group will get buy-in from co-workers and associates because everyone faces the possibility of such circumstances, at some point.

When a plan is not in place, steps may need to be taken.  Fortunately, some people have the insight to recognize increasing limitations.  However, others have to be firmly counseled.  Because discrimination on the basis of numerical age must be avoided, competency, rather than age, should be the basis for any action.  Age discrimination is not an uncommon claim in workplace litigation, consequently, some jobs to have mandatory retirement ages built into employment agreements.  Yet, all of us know of very senior individuals who show no signs of slowing down; and - on the flip side - we know of those whose abilities seemed to have tapered off far earlier than otherwise expected.

The best overall solution is to establish a retirement pathway, one that allows for more senior members to shoulder increased administrative responsibilities, and avoids the type of battle faced by many practices in which less experienced "Baby-boomers" wind up unintentionally in charge.  Rarely do the more neophyte understand issues that face their maturing predecessors, and the situation can become tense and uncomfortable for all concerned.  Honesty and communication are extremely difficult in hindsight; unless pathways have been created to prophylactically deal with such issues, the character, mood, and even the stability of the group can all be placed in jeopardy.

Motivation for Visit and Patient Satisfaction

 

 

A classic history and physical exam is a key component of the medical interaction and record of the patient and provider.  The goal is a coherent, focused account of the visit in the chief complaint and history of present illness area of the chart.  Electronic and paper charting templates prompt one to include the components for completeness and billing codes.

 

They are many techniques to obtain this information, but most leave out a crucial bit of information that may lead to higher patient satisfaction scores while dramatically speeding up the process.

 

This crucial component is patient motivation for taking the time out of their complex lives to obtain medical care that may take up to 6 hours and still not answer their questions. 

 

Patients are motivated by multiple reasons:



• Fear of Illness - I was worried that I was having a stroke or heart attack!
• Family related - My spouse made me come.
• Accident or insurance related
• Problem that has persisted with no "magic cure" in sight

The list goes on...

Asking the patient the circumstances and their concerns of the visit initially will narrow the scope of the visit dramatically.  This allows the provider to focus on the acute problem at hand.

Eliminate the classic response of "You're the Doctor" - you should know and figure out what's wrong - and address their psychological needs.

Your patient will think you are an astute clinician who cares.  Your satisfaction scores might go up and the #1 complaint of the provider didn't listen to me will go down!