Meaningless Disuse!

Guest blogger Dr. Donald Kamens, MD FACEP gives his take on Meaningful Use and where we are today.

It seems that Uncle Sam, healthcare, and technology mix about as well as oil and water; maybe worse.  The problem is not only the ObamaCare tech debacle, actually. Ever since 2004, when the government thought it had to protect its interests (read Medicare) by assuring that data acquired in health care delivery was accessible, parse-able, and otherwise capable of supporting arguments to decrease reimbursement, it has tried to become a techie agency.  And O, how it has tried. 

At first there was a fledgling effort to create an office in DC to oversee healthcare IT, the ONC (Office of the National Coordinator).  In the near-decade since its instatement, there have been five (5) chiefs, only one of whom lasted for a full two years.  There is currently an acting chief, and likely, he can’t wait to get out of there either.

In its beginning the budget numbers were in the neighborhood of about $24M (thirteenth letter of the alphabet).  Since the advent of incentive programs based on the demonstration by vendors of EHR products of Meaningful Use, the bill is more like $70B+ (that’s the 2^nd letter of the alphabet).  What gives?

It is the result of an extreme paranoia.  Clearly a total mental distortion that says:  “if we don’t know what is going on (in there), then we cannot come down on them enough to cut payments.” “So, we gotta know.” “And because we gotta know, we have to bribe the physician population to use devices to record what is going on.” $70B+ is a pretty big bribe.

What baloney.  Recording of medical record information has its historical basis on two needs:  to remind the physician what was done, last time; and to inform anyone covering in case the patient shows up unexpectedly.  Well….you give ‘em an inch…..and what happens… the legal world gets in on it and begins to use these notes to claim malpractice.  And then the insurance companies get in on the deal to determine what the will refuse to pay.

It’s just not needed.  Most all medical encounters can be summarized in just a few words.  If a study is being done on some clinical entity, then a bit more data would surely be of value.  But really, does anyone need 13 pages for an ED visit?  Or 8 for an urgent care stop? 

It’s time to get rid of this Meaningless Disuse program, and its huge expenditures that could otherwise fund significant helpful programs, and perhaps institute a Meaningful Pen/Tablet program. Or even a Meaningful Interface program that works like an ATM, or even as well as iTunes.  Give each doctor a new pen, or an iPad, and let him keep it if he can fill out an accurate chart, or template, in under 2 minutes.

Many physicians like EHRs; most don’t.  Those on the “no” side usually recognize MU is a severe piece of government overkill, that is doing few people any good, while creating long waits in many places as the staff struggles with machines.  

Malpractice Reform

Medical-legal issues always reside in the back of the mind of any provider whether the fear is realistic or not.

In the article, A Failed experiment: Health Care in Texas Has Worsened in Key Respects Since State Instituted Liability Caps in 2003,  it states that the evidence proves that medical testing does not decrease even in a provider friendly malpractice environment.

Attempts at reform include caps of pain and suffering, full-disclosure programs, provider education, provider education with the malpractice statistics have not fundamentally changed the "Adversarial Relationship" that providers have with attorneys.  Physicians are unable to internalize this as a "cost of doing business".  The long-term psychological effects on the defendants are real but hard to quantitate.

A plan of action is to adopt the New Zealand no-fault workers' compensation type system that eliminates the blame game and hopefully makes the patient whole.  The best solution to a malpractice suit is never to be named at all.

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".

Could Your Electronic Health Record Function Without Workarounds?

The Electronic Health Record is a complex tool that hopefully improves communication, fix the legibility issue, and decrease medical errors.  However, the "Devil is always in the details".

Wikipedia states a workaround is a bypass of a recognized problem in a system.  A workaround is typically a temporary fix that implies a genuine solution to the problem is needed.  But workarounds are frequently as creative as true solutions, involving outside the box thinking in their creation.

Computer software that causes a computer to perform useful tasks beyond running the computer itself is called Application software, program, or app.

A GUI widget or control is an element of a Graphical user interface- GUI that displays information arrangement changeable by the user, such as a window or text box.  The defining characteristic of a widget is to provide a single interaction point for the direct manipulation of a given kind of data.

A true test of your EHR is:

1. How many workarounds, apps and widgets are necessary additions to make the program usable?
2. Are these add-ons value added or desperately needed to succeed?

These include some of the following resources: Scribes, Physician Assistants, Nurse Practitioners, Medical Assistants, Voice activated technology, Cut and paste, Macros, Typing courses, Artificial intelligence, Warnings, Error notifications, etc.

Some of these additions can add major value superimposed on an efficient, walk-up usable computer program.  The problem is they are necessary at great cost to survive the electronic world.

Number Needed to Treat

Wikipedia states the number needed to treat (NNT) is an epidemiological measure used in assessing the effectiveness of a health care intervention, typically a treatment with medication.  The NNT is the average number of patients who need to be treated to prevent one additional bad outcome (i.e. the number of patients that need to be treated for one to benefit compared with a control in a clinical trial).  It is defined as the inverse of the absolute risk reduction.  It was described in 1988.  The ideal NNT is 1, where everyone improves with treatment and no one improves with control.  The higher the NNT, the less effective is the treatment.

Recently, the American Heart Association and American College of Cardiology gave out new guidelines on the preventing atherosclerotic cardiovascular risk in adults.  These guidelines suggest the most "Americans" being on statin cholesterol lowering drugs.  This has created some controversy.

NOT being an expert, I cannot tell you whether these are ideal suggestions, but as a consumer there is a question to be asked.  How many people need to take these medications for life to make it a valuable endeavor?

All medications include cost, side effects, and compliance by the patient.

Conclusion- ask your provider and/or pharmacist for all chronic medications, what is the number needed to treat to obtain benefit from these ongoing therapies.  Once you know the number, work with your provider to assess your risk and need for any and all medications.

Value of Scribe Vs. Voice Activate Technology (VAT)

This is an interesting problem with strong advocates on both side of the equation.

After going to the recent ACEP conference, it was apparent that scribe companies are coming "Out of the Woodwork" to offset the labor intensive enterprise Electronic Health Records being imposed on most emergency departments.  Scribes cost approximately $12 - $18 per hour each.  To offset these costs, the provider must see 2 - 3 more patient per shift.  At this point with a general reduction of 20% of productivity per provider, this is not happening overall.  Providers are struggling to stay even.  In institutions where a scribe can function as a medical assistant, a "Go-For", data acquirer from the old medical records, interact with the patients, and print discharge instructions and prescriptions, the extra work is a plus.  This is how most urgent cares function with an all-encompassing medical assistant with multiple roles.  In institutions where the scribe just inputs what the provider states, they are expensive transcriptionists and typists.

Voice Activated technology is an extremely efficient alternative to transcription at much lower overall costs. The provider can dictate key components of the history of present illness and the assessment and plan- medical decision making sections of the records.  This creates a unique non-cookie-cutter chart which helps the private MD, consultants, and your own colleagues, if the patient returns for follow-up.  The problems come in where the EHR is not directly designed without a lot of work-arounds to allow easy dictation.  The initial cost is $1,500 per provider, but transcription costs $7 - $8 chart and the money is regained in time with increased productivity.

Which one is recommended?  It depends on the work flow of the ED, the EHR, and the personality of the provider.  My personal preference is a user-friendly EHR and VAT, so you can take the savings to buy more physician assistant and/or nurse practitioner FTE's.  This hopefully will lead to increased throughput, higher revenues, and increased patient and administration satisfaction.  If my scribe is an all-purpose medical assistant, this would make a reasonable alternative.