"Hindsight is Always 2020. Ask My Dog"

After reading and digesting the article What Will EHRs Look Like in 2020?, my partner Don Kamens, MD had some insight to share- Enjoy!

 

When a physician practicing 15 years from now (2030) looks back one decade (to 2020) will he or she see a quantum leap in usability and functionality from our current time?  Certainly, in the decade 2005 to 2015, the leap has not been quantum, but impaired.  Impaired by such encumbrances as MU (meaningful use) and similar constraints that require caregivers to work with keyboards and mouse, rather than with patients. 

Interestingly MU is also the answer to a famous Zen koan that means "nothing, nothingness, or not at all." It applies in the EHR realm too. In Zen, the question that yields MU, "Does a dog have the essence of Buddha?" contains about as much meaning as meaningful use in the EHR realm. None. Ask my dog, he will tell you. Or he will bark at you.

EHRs bark at physicians too.  Ask the users.  As one punster said, "it's a ruff situation." Indeed, after a particularly trying shift, most ED docs would rather be wresting with the pit bull who bit the patient in room 14, than with the EHR to complete notes, and get home.  Many would choose the dog as an easier path .  

It is also interesting that a section in the JAMIA article is headed Billing Requirements Now Drive Much of Documentation.  Now?  Billing requirements have been driving documentation since well before the advent of EHRs, as they are now known.  Indeed, "justification of evaluation and management codes" has been with us for many, many pre-silicon decades. The difference now is that these justifications are now viewed as electronic data, rather than as marks or notes on paper.  But the information is not substantively different at all; it is identical, just gathered and assembled differently, and more transferable, interoperable. Severing the calcified link between a physician's account of clinical work done and payment received will need  surgical intervention. Many are pushing for outcome-based reimbursement schemes. But few physicians want to see outcome-based payment systems, as those with poor outcomes sometimes require the most work.  

What is missed in this analysis, is that the EHR in 2020, when looked at with 20-20 hindsight, should not repeat the mistakes of the past.  But it will.  It will because the perspective of guidance in this realm is incorrect, and far too quantitatively based.  Medicine has quantitative aspects, but it is far from a quantitative science. It is largely qualitative, and heavily subjective. 

What is the fundamental mistake that has been repeatedly made with EHRs that will perpetuate the sins of the past?  Well, one would hope that in 5 years, approaching the EHR on a case would be greeted with a sigh of relief, rather than with the trepidation of taking the first step from basecamp to climb Everest.   EHR developers should be using the experience of video games, Roku's, automobile driver interfaces, Khan Academy, from (yes) smartphones and cool apps.  It's not happening at the moment.  And it is not happening particularly because of the constraints that MU and related rules put on the system.  

Ask any Zen adept. Emptiness ! MU is nothing. Or ask any ED doc forced to use an EHR that drives him or her nuts.  Or ask my dog.

Scientific Basis of "OM"

The power of meditation is explained quite well in the article, From OM to OMG: Science, Your Brain, and the Productive Powers of Meditation.  It analyzed the brain by MRI scan that is meditating to the normal active brain.  She claims it leads to better focus, less anxiety, more compassion, more creativity, better memory, less stress, and more grey matter.  The aging population especially myself can use all of these.

Meditation turns off the tumultuous, endless thoughts produced by the brain allowing one to focus with mindfulness on nothing or a particular pathway.  OM or any mantra is a sacred utterance, numinous sound, or a syllable, word, phonemes, or group of words believed by some to have psychological an spiritual power is a vehicle to achieve a meditative state.  OM is the vibration of the universe- more than a sound, but the vibration.  What's the bottom line for most people who are skeptics?  The benefits outweigh the negatives of trying it.  What if it really works?  Take advantage of easy solutions to complex problems.

This is all well and good for those who wish to spend time in a cross-legged position, or chanting, or meditating on koans, but one would eventually be led to ask, "What is brain anyway?".  What is mind?  As the Zen adept will note: if you understand, well then, things are as they are.  And if you do not understand guess what?  Things still are as they are.  Quite likely the brain exists in the physical universe very much like a smart phone on a plan; the data probably exists in multiple dimensions, and as the phone works and the brain has not stroked out, the information is there.  But does it matter that we get it?  Indeed when asked to walk the dog one should first reflect on the hope that someone's karma does not run over your dogma.

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.

Zen and the Art of Human Medical Maintenance

The word Zen is derived from the Japanese pronunciation of the Middle Chinese word dzjen, which in turn is derived from the Sanskrit word dhyana, which can be loosely translated as "absorption" or "meditative state".

Zen emphasizes the attainment of enlightenment and the personal expression of direct insight in the Buddhist teachings.  As such, it de-emphasizes mere knowledge of sutras and doctrine and favors direct understanding through zazen and interaction with an accomplished teacher.

Wikipedia describes the following for evidence-based medicine- EBM:

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.  Trisha Greenhalgh and Anna Donald define it more specifically as the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients.

in the novel Zen and the Art of Motorcycle Maintenance: An Inquiry into Values is a 1974 philosophical novel, the first of Robert M Pirsiq's texts in which he explores his Metaphysics of Quality, the author attempts to reconcile the natural, inexplicable forces of nature with an analytical approach to everything.

A comparable task is the fine tuning of EBM with the "Art of Medicine" to enhance the quality of medical care received and given.  This would lead EBM to become "Evidence Enhanced Medicine".