Monday, December 28, 2015

Preserving the Mental and Physical Health of the “Graveyard Workers”

In the article 8 Ways Working the Night Shift Hurts Your Health, authors suggest that working night shifts can lead to 
  • Sleep disorders
  • Increased diabetes risk
  • Increased obesity risk
  • Increased breast cancer risk
  • Altered metabolic state
  • increased risk of heart attack
  • Increased workplace injuries
  • Depression.
Any medical provider can add to the list:
  1. Anxiety
  2. Drug Abuse
  3. Alcohol abuse
  4. Marital discord
  5. Family stresses
  6. Increased Errors
  7. Career dissatisfaction
  8. Burnout
  9. Vicious cycle of sleep/circadian disturbance
  10. Impaired judgment
  11. Etc., etc., etc. (Add your own) 
In industry, most major mistakes happen between 2-4 AM. This occurs even with workers who exclusively work nights on a consistent basis.  Yet, most medical practitioners work night shifts intermittently, and the on-again/off-again cycle of this scheduling dramatically alters circadian rhythms. As a provider gets older, especially after passing the age of 50, these issues get more pronounced, more difficult, and sometimes worsen to an extent that make them very visible to others.
What’s a person to do who has chosen the EM lifestyle without foreseeing all its potential consequences?  An article in web MD gives some steps on avoiding work sleep disorder.  It is titled Could you have shift work sleep disorder? It can be found at: ( )
The underlying purpose of this blog on the topic of night shifts is to remind everyone to “LOVE” and “CHERISH” any body (yours!) willing to work night shifts. Doing so is not easy. It can be especially difficult for those of a hardened EM mindset, who not uncommonly beat their bodies into submission, just to accomplish the work.  Most of us have been there at one time or another.
Just as it is hard to quantify the dangers of ignoring one’s own mental and physical health needs, so it is equally difficult to quantify the other side of that fence: the important psychosocial benefits of self-care. Ignoring reminders we get in this area comes at a considerable price.  Being an ostrich, in this turf, has deep ramifications.   The winds still blow over the plain when the ostrich head is below it, but its body is still exposed. Costs come in terms of physical health, mental health (paranoia), social isolation, and difficulty fitting in with the rest of society (populated by other birds that have a “normal” work flow).
For those who have reached elder status, continue to work, and have sweats and shakes if a night shift is scheduled, those who are willing (or sometimes coerced) to do nights-only are precious commodities.  How do you keep them alive, happy (or at least not miserable), and preserve the benefit they give? Most importantly, reimburse them well with shift differentials, RVU’s, control of their own schedules, psychological support, and ears that remember to “listen to them”.
Don’t underestimate the need to pay attention to them. They are usually working in an environment that is fundamentally different to the day shift. Their concerns might not be appreciated and/or respected. And sometimes just listening has great benefits, even when no action is taken, or can be taken.

Monday, December 21, 2015

Malpractice Worries Enter a New Level of Sophistication and Complexity

Malpractice claims are usually rooted in poor communication, failure to diagnose, bad outcomes, and poor interpersonal relationships. This has been exacerbated by the Electronic Health Record, increasing sophistication of the lawyers, and an antiquated malpractice system that assigns personal blame to the provider creating an acute-on-chronic adversarial relationship. The doctor/provider-patient relationship is supposed to act in harmony to provide physical and psychological care to the ill.
10 New Malpractice Concerns, and How to Avoid Them article is a highly recommended read for anyone practicing in high-risk fields.
The author suggests that there are 10 new risks in addition to the usual suspects.

1.       High deductible insurance plans (de facto self-pay) are forcing patients to eschew their treatments or follow-ups. They recommend you document the potential seriousness of the problem.

2.       Following clinical practice guidelines that are not necessarily the standard of care in the community to save money. The standard of care is established by the specific jury of an individual case.

3.       Accountable Care Organizations (formally known as HMO’s) function on the basis of providing coordinated care while spending less resources. This does not matter to the individual patient who feels they have a bad outcome due to organizational/rationing of their care.

4.       Team Care which means the physician, nurse practitioner, physician assistant, nurse, social worker and etc. working together with no obvious leader in charge. Make sure everyone knows their level of responsibility.

5.       Having Smart Phones distract you. Patients usually mistrust providers who take non-emergent phone calls during a visit. This also includes having your back to the patient typing on the Electronic Health Record with no eye contact.

6.       Social Media should be avoided.

7.       The Electronic Health Record has a slew of potential problems. These have been elucidated in previous blogs endlessly. The biggest problems are 1. Cut and Paste Macros 2. Inadvertently clicking on data points that really have not been performed. 3. CPOE issues 4. Ignoring alerts 5.Not realizing that metadata is being collected that states when, where, and which computer the documentation occurred. 6. Time stamp issues 7. System errors with lack of training and systems not specifically designed for certain locations. 8. Lack of easy access to the nursing notes. 9. You may be obligated to know the entire past medical history including pharmacy because it is potentially available 9. ETC.

8.       Telemedicine has been predicted to be 5 years away from serious litigation. This includes liability and breaking state Board of Medicine rules. Every state has different rules and your malpractice coverage may not cover you for Board of Medicine complaints.

9.       Employed physicians are at the potential mercy of their employers. One may not have a say in the legal defense or the battle plan.

10.   Complaints to state boards can be worse than malpractice. You are usually guilty till proved innocent and have to pay your legal costs. Some states like Florida have 3 strike rules where a complaint the Department of Professional Regulation counts as a strike. This can be life-disrupting. 

In conclusion the best way to stay out of trouble is good communication and GOOD LUCK!

Monday, December 14, 2015

Can Defensive Medicine Decrease Lawsuits?

The authors of Physician spending and subsequent risk of malpractice claims: observational study try to determine whether increased clinical use of diagnostic resources serves to decrease malpractice claims. While they were able to show an association between greater physician spending and reduced risk of malpractice claims, they were unable to determine an underlying cause for increased resource use.
That is, the reason (cause) for this association is not entirely clear.  We can speculate, of course, but it is wise to remember that doing is simply that, speculation.  
Consider two possible causative explanations, one employing a defensive approach, and the other an offensive approach.  Opposite forces, same result. How?  In the first, physicians studied may actually have practiced defensive medicine, with the mindset of defending themselves from lawsuits. In the second, they have practiced offensive medicine, being more careful for the benefit of their patients, and being little influenced by defensiveness.   In either case the same association would have been shown: more tests, less suits.  Indeed, it could be the case that more careful doctors make more accurate diagnoses, and have fewer suits.  The only difference between these obverse sides (defensive/offensive) is motive.

From the defensive side, the authors give multiple reasons why malpractice occurs where some skill improvements might be of benefit, including poor interpersonal relationships and impaired communication abilities.  From the offensive side, when one is doing one’s best in behalf of a patient, there is little that can be done about unanticipated bad outcomes, unexpected diagnostic errors, cognitive errors, and systems errors. These happen to the best of us.

Nevertheless, defensive medicine is a fact of life for most physicians in the United States. It is present to some degree, even if slight, in most of us. It is the “Elephant in the Room.” Even though multiple studies contend that malpractice risk is overrated, those of us who have practiced for more than a few decades (or more) know that a multiplicity of factors get poured into each clinical decision, and no less into the question of what tests to run. While defensiveness may creep in now and then to some degree, it is not the whole picture, as it simply does not control clinician minds. Most of us make decisions based upon that we think will benefit the patient, not upon what will keep us out of court.  True, a good outcome is less likely to result in a suit, but we tend not to live in a pessimistic world where every patient is a lawsuit waiting to happen. Some believe that physicians do think that way, but it is an untrue picture because most practice optimistically.

Yes, there are those who have allowed defensiveness to rise to the top in their decision-making.  But not all in the house of medicine have done so.  No, not all, and more precisely, only few have defensiveness dominate.   Of course, for each of us, there have been times it has become more of a force than we would like, perhaps when under stress, or perhaps when the memory of encountering a plaintiff’s attorney is still fresh. But for the most part, we get back to practicing primarily for the sake of patients, letting potential litigation chips fall where they may. We do that largely because we know that lawsuit apprehension is not what really motivates us, nor what is best for our patients.

Unfortunately, a big part of the malpractice setting is the psychological and emotional damage a suit inflicts on defendants. Loss of money may happen; worse are losses of self-esteem, meaning, and identity. Then there are the potential appearances of alcohol abuse, substance abuse, and marital discord. These are only a few of the untoward consequences that accompany becoming a malpractice defendant.  There is also the chances one may lose their job or that potential advancement may be spoiled. The state of Florida has a 3-strike law that can actually force one to leave the state. We have been told that being referred to the State Department of Regulation can be a worse experience than being sued.

A provider who is currently, or was previously, a defendant must live with a cloud that follows him or her around, raining thoughts about the “mistake” that may have harmed someone. Whether fault really was present is often irrelevant when the defendant bears psychological consequence. Endless pressure to perform at 100% accuracy in a world where errors are not taken lightly, may, over time, extract a toll on the joy and satisfaction practicing medicine should otherwise have. One sometimes hears youths, as well as mature ones, say that medicine can be a great career, but there are easier ways to make money.

It is important to be cautious and, as we have noted, caution can lead to greater expenditure and resource utilization.  But, as we have noted, cautiousness may be directed not only toward oneself (defensively, by the ordering physician), but also toward the patient (offensively, to be sure nothing important is missed).  Now, when we, or one of our loved ones, becomes sick, don’t we want the cautious, caring physician, on the offensive in your corner, whether his ordering stats appear to be “defensive” or not?

Are there any solutions to this conundrum? Having a non-combative no-fault malpractice system (as in Australia) would be a good start. While a no-fault approach does not eliminate malpractice claims, it enables most injured patients to get their day in court without demonizing the provider.

Communication and system issues are prime sources of patient dissatisfaction. Still, because little can be done to reverse a bad outcome, a no-fault system has definite advantages.  It has the ability to provide resources for the patient and the family, while simultaneously protecting all concerned, including the physician.

In conclusion, it is only logical that providers might order more tests to protect themselves from all the downsides of lawsuits.  On the other hand, it is also only logical that physicians order tests in larger numbers to protect their patients from bad outcomes.  How do you tell these apart? These two paths to more testing are indistinguishable.  But in either case, even though the provider is being risk averse for two apparently different reasons, ordering more tests will not prevent lawsuits.

Monday, December 7, 2015

The Unintended Consequences of Good Intentions!

Another guest blog from Dr. Donald Kamens on the health-care exchanges- a personal experience.

Sometimes the symptoms of a disorder are the best clues about etiology.  In the case of healthcare insurance 2016, we have a disorder that is a horse, but not a zebra.  Why? Some would have you believe that rising costs are secondary to the high cost of emergency room care (zebra, or baloney, whichever seems more appropriate).  However, any individual not provided insurance by an employer, can try to buy coverage independently (or for a family member). Thereupon, the horse comes out of the barn.
So what is the breed of that horse?  Is it a Quarter-horse, an Andalusia, an Arabian?  No indeed.  That horse, is a Complexity-horse.  A tough breed, difficult to train. In fact the complexity here is so intense, that a new specialty has arisen:  the CAC (Certified Application Counselor).  Why?  Because applying for coverage is so complex that guidance, or counseling, is needed.  Well, it does not take a rocket scientist to figure out that if a system requires that it spend money for advisors to help hold the hands of applicants, something deeply internal is wrong.  The complexity is just too costly, in and of itself, regardless of the costs of care! What a conundrum!

Now, here’s a live example.  I have been trying to buy healthcare insurance for my wife. She left a teaching position several years ago to pursue other dreams, and that meant finding our own insurance plan.  In November 2016, that is so complex that the neighbors, many miles away, may well hear me screaming.  My years of working in this milieu, as a physician, as an administrator, and as a group principal, do not impact the sense of swimming through spaghetti.  Here are just some of the issues I ran into:

1.     The “marketplace” is impossible to discern.  Every state has its own pallet of availabilities, and within those, each company there is a bewildering spectrum of plans.  The website pages are impossible to read.  Even with page expansion on 36 inch screens, my wife even took pictures of me pouring over them with a magnifying reader.

2.     There is a proliferation of acronyms, incomprehensible terms, and head-scratcher delineations.  IF (and that is a big IF) one gets to see them, one has to do considerable deciphering.  DED means deductible; yes.  But then, you have to figure out and research many (many) others (e.g. PCY  ...per calendar year.  Something wrong with /yr.?). There are tons more.  And then, do you know what $1/$5/$15 means?  In some places (but not all) it means tier 1/tier 2/tier 3 drug costs. 

3.     The plan listings are in disorder.  For one company I was examining, there are bronze, silver, and gold plans. Fine, the idea is clear that gold is best, and so on.  But not so fast.  In this one, they are listed with bronze at the top, gold in the middle (though the costliest), and silver at the bottom being the only one with no drug deductible. What?

4.     The websites do not work very well.   Not uncommonly one gets bounced and has to start over, or some button does not work. Or worse, as on one site, things start acting crazy.  Here, it asked me the number applying for coverage [=1]. Then the number of people living under the same roof, including those not applying for coverage [=3]. Then it said “Sorry the number in your household does not correspond with the application number.” Seriously. Really.

5.     This is a mess!  Did I say that before?  The intentions of those who have set such things up, we have to believe, were good, even if modified by legitimate business concerns.  However, the outcome of this complexity is going to shoot the whole system in the foot. Or the head.
Worse than being a mess in just one state, think about setting up all these complex plans for 50 states! It has been no easy task. Nor was it free.  How much chemotherapy for a patient who could not afford treatment could this baloney have paid for?  I would estimate that if the amount spent on the complexity of the system were actually put into delivery of healthcare itself, the benefits to people would be immense.  This insurance mechanism is a waste of money, a waste of time.  And the real benefits to people are, I would venture to say, going to cause more problems than anyone needs.

Finally, here is my suggestion for an insurance application having five parts:

1.       Do I need health care coverage?  [  ] yes   [  ] no

2.       What is my income:  _____________

3.       How much can I afford per month per individual or per family for coverage?

[  ] $0 [  ] $10 [  ] $50 [  ] $100 [  ] $200 [  ] $500 [  ] $800 [  ] $_______

4.       Do I have any known illnesses requiring care? [list] _______________

5.       When do I want it to start? ____________________

In the past, when colleagues said they were leaving medicine because it was becoming more and more difficult to practice, I tended to think “wimp!”  Now I am myself thinking of leaving the country and finding a more rational solution to just being a citizen who might, or whose family might, need care someday.



Monday, November 30, 2015

Urgent Cares, EDs, Reliability, Reputation, and the Rise of New Paradigms

A guest blog from my colleague and friend, Dr. Donald Kamens.  Enjoy!

Several weeks ago I happened to be walking down a street in Brooklyn, NY, when a downed sign tripped my step.  Likely it was my clumsiness, or my age, that were the big contributors to that fall, the result of which was a cut lip and profuse bleeding.  Getting back to my room with applied pressure, it was clear some stiches were needed.  The wound was not terrible, though somewhat complex it did not cross the vermillion border, so repair by a competent ED physician, or an experienced PA working under one, seemed the best bet. No plastic surgeon needed (as yet).  I decided on going to an UC, to save time, effort, and avoid the crazy waiting rooms of larger NYC hospital EDs.

It was a Sunday, around 1pm, and Google showed four or five urgent care centers, all open for a few more hours, within several miles.  That became my plan to get this minor boo-boo fixed. If I’d have had two-hands, an assistant, and some equipment, I’d have done it myself. But no. So here I go, to the other side of the doctor-patient virtual fence, becoming a patient, an ED doc in an environment familiar but unnatural to him.

Of the UCs in the area, two were owned by a doc I’d known for decades; I kept looking.  The other three advertised “a full staff of 13 (or in another case 15) board-certified emergency physicians on staff and one always on duty,” “we can handle anything,” etc., etc.   Bingo.  So I picked one that seemed closest, just over the Brooklyn Bridge, called to be sure, and got the message “we are open ‘til 6pm on Sundays, and waiting to help you,” got a cab, and headed there.

The sign on the door said “closed today.”  What?  Really?! Okay, will deal with it. So far I’d used nearly a full tissue box compressing the wound. Got another cab, asked the driver to head back over the bridge, and called UC#2. After describing the small, relatively simple, facial wound to the female on the other end of the phone, she said “let me check with the provider on duty.” Note: no mention of “the provider on the premises.” Several minutes later she returned and said: “I’m sorry, we cannot handle face injuries here, you will have to go to an emergency room.”  Seriously!?  I wanted to say “Can I use a few ccs of xylocaine, a needle-holder, and some suture? But they did not know me from Adam, and not to be fully beaten down from the UC concept that I have supported for decades, I tried the third on my list, telling the driver I’d give him a target address as soon as I knew it.  “Sorry,” the UC desk person said, “We have no one here that can handle a laceration.”  Where am I? Sub-Saharan Africa? No, I’m in Brooklyn – NYC. So I bit the bullet and went to a not-too-distant large metropolitan hospital, whose director I’d known for years. The waiting room was not overwhelming, I was cared for in minutes, and out in under an hour, of which maybe 20 were taken up with wound repair itself.  On the cab-ride back, and the in the hours and days afterward, this experience left me scratching my head, and thinking.  

Reputation and Reliability:

Urgent Care centers have skyrocketed into the US healthcare scene, and not without reason.  They promise things that EDs cannot fully guarantee:  short waits, quick face-to-face with a provider, and decreased cost and complexity.  What became clear to me, as a proponent of this development, is that the UC, as a site of care-delivery, has not yet matured.  Hmmmm.  Now, what would such maturation look like?

For one thing, there would be recognition that reputation for being reliable (at least for the key components of immediate care) is an essential piece for success of the whole concept. Independent UC have a need to promote a reliability reputation not only for their own success and survival, but also for all others. That is, if, for example, a person goes into an ED in Newark, NJ, and has a downright terrible experience, then when later in, say, Los Angeles, needing ED-type care, that previous terrible experience, a full continent width away, will inform the real-time choices that person makes. In the same way, experience in an UC on Long Island will inform the consciousness, and care-choices of a patient who may need care later in Georgia or Florida. Thus, UCs are not independent of one another with respect to reputation. This is especially so in these early years of the UC paradigm.

Fortunately an organization like UCAOA has an opportunity to impact the entirety of the emerging specialty by developing criteria that best-practice UCs work to meet.  No, these won’t always reach full compliance. But operators of UCs should be aware that what they do on an individual basis makes a difference to all UCs. What happens in a UC does not stay in that UC.

And, while UCs have a spectrum of capabilities, from “free-standing” EDs to PA-only, the reputation of the entire UC endeavor pivots on reliable, honest, and dependable advertising.

New Paradigm

No matter how one views emergence of UCs, its paradigm is new-kid-on-the-block in the US healthcare landscape.  Welcome, for now, but needing some “getting-used-to.”

UCs arose because of need, as do most elements of the healthcare system, from penicillin to fiberoptic intubation. In UCs case it was the complexity and difficulty of encountering an ED; the seeming failure of ED “fast-tracks” to actually be “fast” as their rooms were taken over by critical-side overflow; and the overlying gray-cloud of cost that EDs seem unable to escape.

At this point in the infancy of the UC paradigm, those who operate them should be keenly aware of the importance of building reputation. And, as noted before, the communal reputation each UC generates for all others.

For me, at this moment, if (when) I get crushing sub -sternal chest pain, I know where I will go, and it will not be an UC.  If I fall and cut myself again, or if I develop bronchitis/pneumonia, it will be a head-scratcher (unless my hand is bleeding badly). While, minor injuries, wounds, lacerations, and upper-respiratory and GI infections form the bread-and-butter of UC operations, not all people understand these distinctions.  What they do understand is that UCs generally promise quick in-out, dependability, but with a more limited door-open time than EDs. I think that UCs would want me as a paying, insured, patient, who generally causes no trouble. Maybe I am wrong. But I am hoping, for my sake, and for the sake of my family, that those I love are able to rely in the future on those places that are opening up all over the map.  If real-estate uses the three Ls, UCs should be thinking the three Rs (reputation, reputation, reputation).

Monday, November 23, 2015

The Time of Highest Risk in Emergency Medicine

Medical care has always claimed that certain timeframes as critical to life and limb. Examples are 1) The “Golden Hour of Trauma,” 2) 90 minutes to PCI for a heart attack, 3) 90 minutes to receive TPA for strokes. The numerical value assigned for each of these times is subject to ongoing debate, and so the consensus changes periodically.
ED physicians generally agree that the interval of greatest risk for patients is during shift change, and its resulting turnover of care from one provider to another. This period of higher risk impacts nurses, physicians, techs, and all other providers. Indeed, the well being of the patient is highly dependent on the communication skills and the other established processes of a facility that transition their care from the old, departing, to the new, oncoming, team
The article Handover in the emergency department: Deficiencies and adverse effects delineated the problem way back in 2007.  The author’s state:

“Deficiencies in handover processes exist, especially in communication and disposition information. These affect doctors, the ED and patients adversely. Recommendations for improvement include guideline development to standardize handover processes, the greater use of information technology facilities, ongoing feedback to staff, and quality assurance and education activities.”
Nevertheless, the “turnover problem” and its obvious risks still exist today, despite that fact that many EDs and some EHRs have tried to create processes to limit pitfalls and liability. Since the early 1990’s XpressTechnologies included a structured turnover note with its comprehensive set of templates.

The idea behind the turnover note was to facilitate systematic communication from a first provider that to the next provider, in that note was key information on the nature of the case, state of workup, and expected outcome for the most likely clinical course. The details included:

1.   Pt name and location

2.   Course so far: a) Initial presentation b) workup done c) communications made d) workup anticipated

3.   Key tests awaited (needed for disposition).

4.   Anticipated optimal clinical scenario for patient disposition, patient satisfaction, best outcome (repeat physical, see if patient improves, etc.)

5.   Consultant names and contact numbers (primary physician, expected admitting physician, referral physicians, and consultants called or coming).

6.   Cautions (what to watch out for, any risks to keep an eye upon)

The note was structured to allow brief, clear, few-word responses that could be seen at a glance. Still, the turnover process has historically not done a good job putting down key information was actually conveyed to the patient.  For example:

1.   Was the turnover done at the bedside? As a three-way discussion?

2.   Was the patient (and the family) introduced to the next provider?

3.   Was a game plan reiterated for all; to patient, family, and caregivers?

Top ED physicians know, perhaps a bit subconsciously, that going through these simple steps helps avoid disasters of the type that turnovers sometimes create.  They know that avoiding abrupt hand-offs like:  “if the tests are negative, discharge the patient,” helps avoid disasters and increases patient and family satisfaction.  But is that avoidance always accomplished?  When we are leaving, and convinced everything will be fine, do our wiser minds always rule?

Suggested safeguards are:

1.   Have an organized plan that people adhere to.

2.   Have turnovers rules. Include rules about how many turnovers are allowed, about types of patients allowed and disallowed, about expected time before the new doctor returns to check, and about what to do if unexpected problems arise (e.g. the family is at the nurses station complaining that the doctor has not been back in hours).

3.   Providers should be realistic about the nature of emergency practice. We just do not always get to leave when the posted coverage schedule says we should.  And so it is a bit dangerous (especially to the patient) to be obsessed with “leaving on time.” Compensation models can be adjusted to reward the most conscientious practitioners, and some practices find ways to avoid inadvertently encouraging providers to quit seeing new patients too early. A team approach can be created that so that reasonable turnovers are readily accepted. Doing so for others, and doing it safely, means the same can be done for you.

4.   The bottom line is that high-risk turnovers can be transformed into low-risk patient and provider communication opportunities.  Careful planning and appropriate rewards for those practicing this kind of safe medicine can really benefit patients, hospitals, and ED teams.

Monday, November 16, 2015

The Coming Electronic Medical Records "ARMS RACE" to Support Value-Based Care

With the advent of value-based care, the EHRs aren't enough for value-based care blog is a very succinct analysis of the need for radical change in the electronic health record.

The author states that the EHR must be capable of importing longitudinal lifetime data from any patient to assess the value of any given treatment or evaluation.
This means that the provider must process all the past medical history and up-to-date treatment and evaluation protocols in determining how to proceed.  The typical provider has neither the time nor energy to accomplish this goal without lots of help.

The new Electronic Health Record will have to:
  1. Attain a level of interoperability through out the entire medical universe.  A good first step is a national database.
  2. Both during and at the end of an evaluation, the provider must receive artificially intelligent notifications as what to do next.  The opposite is also true- What not to do!
  3. The EHR will have to link automatically to multiple treatment guidelines and suggestions made by various societies.
  4. The CPOE will have to reflect both cost and effectiveness of any orders or treatment plans.
This obviously is not a simple task with multiple layers of complexity.  What is most likely to happen?

When the new payment guidelines are released:
  1. The EHR developers and the providers will have to program the EHR to notify the provider of what documentation needs to be filled out in order to get paid.  This will have to be a dynamic function as the rules will be constantly changing.
  2. The EHR at the end or during each encounter will have to present the providers with a checklist of documentation required.
  3. It will be a race to accomplish these goals, so that payments will not be interrupted.
Will this provide better medical are in the long run?  Let us hope so.  If the goal of value based payments is to reduce costs, it will probably be successful because of the new documentation requirements.  However, the technology people will respond as they have in the past to deliver a product that supports the providers.  This will also lead to massive changes in practice management and billing protocols.

Monday, November 9, 2015

The Perils of Alert Fatigue

The authors of Alert Fatigue analyze and define the term as " busy workers become desensitized to safety alerts, and as a result ignore or fail to respond appropriately to such warnings."

They conclude:
  1. Alerts are only modestly effective at best.
  2. Alert fatigue is common.
  3. Alert fatigue increases with growing exposure to alerts and heavier use of CPOE systems.
One of the potential great benefits of the electronic health record is clinical decision support, where artificial intelligence augments the baseline intelligence of the clinician.  The ultimate goal of CDS is to help the clinician 1- make accurate diagnoses', 2- use up to date treatment protocols, and 3- receive warnings about potential diagnostic and therapeutic pitfalls.
Troubles with intelligence (either artificial or natural) rise exponentially with the complexity of any issue.  For example, when one consults the PDR, every drug has hundreds of side effects and warning.  Ordinarily, the human brain filters these risks- many of which are hypothetical-and creates a mental hierarchy of potential dangers, on which action can be based.  However, when a computer performs the task of risk-retrieval, things become much more murky, since filters to prioritize, based on clinically relevant evidence, are pretty much absent, or if present, inapplicable.

Indeed most side effect warnings are inserted because pharma legal teams insert reference to every case report, not matter how obscure.  Otherwise- such non-medical counsels might argue- how could there be good defense against attribution of negligence, should a second atypical case pop up?  Putting such warnings into the adverse effect section of the ubiquitous PDR provides the possibility of escaping a lawsuit on the basis of physician or patient contributory negligence.  That is, the pharma defense team might argue, "they (the docs) did not (even) read the warnings!"

Attending to every one of the countless case-report engendered warnings would effectively take most medications- not to mention the clinicians- out of practical consideration.  On the other hand, some alerts are very serious and represent preventable errors that can potentially be avoided.  Balancing this voluminous input is hard on the human mind, and pretty much- without weighted prioritization- impossible for a machine.  Hence, the machine creates noise- repeated alerts- that the mind must deal with, and clinicians, getting inundated with endless warnings and signals, start ignoring them, even perhaps overriding their demands.

Human-factors come into play.  Protective desensitization to incoming stimuli is a necessary component of efficient cognitive activity.  Who among us has not become resistant to the noisy environment of an ED, just so we could get our baseline thinking in order?  The same can be said of a parent, working at home, with  chattering children running about.  Earplugs?  Well, sometimes.  But for the most part, many have learned to shut down the "noisy" input by "throwing an internal switch", one that no longer hears the kids screaming.  Repeated alerts, as we all have experienced, soon become just background noise.  Hopefully, thought, if the house is burning, the sound will be loud enough, different enough, for a red flag to arise.
This mirrors how an EHR vendor gets trapped into providing endless alerts.  For an EHR company, it becomes a business matter instead of a safety matter, created by potential legal liability.  If the physician doesn't read- and act- on a warning, the defense team might assert, it is not the EHR vendor's fault.  At bottom, these issues become matters of interpretation regarding what was serious and what was not serious when a legal case- or class-action suit- is initiated.  Vendors, understandably regarding their own interests, tend to be ultra-conservative, and this is especially true for CPOE of medications.

The authors suggest:
  1. Increase alert specificity
  2. Tier alerts according to severity
  3. Make only high-level-severe- alerts interruptive
Even with such suggestions implemented, the problems are complicated since most enterprise EHR systems usually provide only globally effective solutions.  By nature, hybrid solutions do not achieve usability in specifically defined care-settings or circumstances.  The example we know best of a specific care-setting in which enterprise systems have failed to meet usability standards is the ED.  In other works, an alert that makes sense for one provider in one care-setting i.e. the ICU may not be appropriate elsewhere, i.e. the ED, nor would its intent and value necessarily be appreciated.

Some vendors have unfortunately left the job of tailoring alerts to the clinicians working at a client facility.  Dumping all responsibility on the docs is truly unfortunate, not only because it means considerable extra work and expense for the clinician staff but also because it nominally absolves the vendor of appropriate involvement in the effectiveness and up to date accuracy of the product.  The ability to do some local customization has definite value, but a balance between what the vendor inputs, and what the clinicians input, is necessary for a system to be effective, safe, and appreciated by all.

Our culture contains multiple myths and stories such as "The Boy Who Cried Wolf", and Chicken Little with the sky is falling.  Alert fatigue is a real entity and will need careful analysis to allow the positive clinical decision support to be a facilitator toward better clinical care and outcomes. 

Monday, November 2, 2015

If It Takes a Supercomputer...

Many of you may have seen recent announcements that IBMs Watson supercomputer is being recruited by hospital centers and the pharmaceutical industry and to address issues in order-entry, patient compliance, risk, and therapy selection. 

Now, you might wonder, why does medicine, at this moment, need a supercomputer?  The answer is straightforward: The practice of medicine is a complex undertaking.  We all recognize that part.  "But what about the rest of us?", you might further ask, "we who cannot afford the millions i.e. billions for Watsons' help."  Any who can afford such an assistant- as could Alex Trebek & Jeopardy, where Watson walked off with the huge prize- are not like us- everyday docs in a practice.
In truth, advances in Health-care IT , such as access to data, the internet, and an ability to simplify regular repeated procedures, have huge potential in medicine, but it is potential unrealized!  Not only unrealized, but also accompanied, in modern times, with pain.  If you are a practicing physician, no explanation necessary.  Who of you sees patients at a faster rate?  How many complete all charts before the end of shifts?  How many fire up their machines at home each night to "catch-up" on the day's work?  Who among you know for certain what you have documented without reading it over through bleary eyes?  Who doesn't wonder about medico-legalities?  Raise your hands please!

More likely your days of late have been peppered by expletives too extreme for publication here.  And this time, they've not been directed at nurses or patients...but at the machine on your desk.

Here is a simplified list of the operations a well-thought out EHR system should provide.
  1. Easy access, easy navigation to necessary tasks.  Easier than a cell-phone.
  2. Simplified completion of charting/medical-record creation, with very few keystrokes, and preferably with voice activation.
  3. Simplified retrieval of previous work-in-progress even if others have used a terminal in the meantime- with immediate return to the previous place upon which you were working.
  4. Presentation of lab, significant data on any patient being cared for with a minimum of keystrokes or clicks.
  5. Background infrastructure (practice management) that allows the facility in which you work to operate efficiently, for the sake of the patient, and for the sanity of the staff.  Look- Amazon, Wal-Mart and Google do it, so why don't we?
  6. Streamlined billing and collection operations that provide immediate reimbursable data to 3rd party payers, billing agencies, other insurers, and patients.
These are doable; they can be accomplished right now using simplified systems, often boutique systems (i.e. non-Watson wanna be enterprise systems).

Removal of the umbrella of baloney- meaningful use, would be a good step at the moment.  Perhaps when it is shown that medicine can address the interface between man-machine (provider-machine) practically, then the door might be open for the larger pipe dreams: sharing of data between distant facilities via standardized interoperability, and safety conscious clinical decision support and error checking.  But for now, we'd just like to get the job done, easily and correctly.  Right?

Until then, we may have to cast an outsider's eye at Watson doing SCPOE- Supercomputer Provider Order Entry, and get back to taking care of patients.

Monday, October 26, 2015

Dilemma of Accurate Data Collection

In the article How your hospital can make you sick, Consumer Reports paints a pretty negative picture of hospital acquired infections.  The data is disturbing, but without context can lead to reaching conclusions and action plans that may or may not work.

The electronic health record contains endless amounts of information, but may or may not provide the precise data researchers seek in an easily accessible form.  Optimally, the EHR collects the data automatically, without need for provider input.  However all too frequently, data is incomplete or inappropriately classified; unless an answer to a specifically requested question is input, the data may become difficult to retrieve.

Most commonly the providers do not know the questions that are needed, and do not therefore record whether they have or not done performed some action.  A good example is not recording that the patient is a MRSA carrier who then leaves the hospital with MRSA cellulitis and dehydration.  Did the patient acquire the infection prior to entering the institution or after hospital exposure?

An EHR can be used as a tool to capture this data.  The providers must know the questions and the  organization must create buy-in to collect the data.  There are various methods.  The easiest is a checklist prior to discharge that answers the questions easily with the ability to provide context.  This context can explain a behavior that may seem inappropriate.  Moreover, it can be entered into the EHR by a non-provider at a latter time.

The bottom line is the EHR can be formatted to help the clinicians answer the tough questions.  This may help various institutions avoid the dreaded headlines in the morning paper(if anyone still reads it).

Thursday, October 1, 2015

ICD-10: The Elephant in the Room

ICD-10: The Elephant in the Room

With ICD-10 “Go-Live” compliance date being 12am - October 1, 2015 (36 hours 45 minutes away as this is being written)1, we’ve been experimenting with the CMS/Medicare resources2, and in particular their ICD-10 code lookup “tool3”.  Our object in doing so was to figure out how to quickly determine the appropriate code for any given case.  Why?

While it is most likely that physicians will not be entering their own codes on a regular basis, some will do so, either by requirement or choice.  In other cases a coder will most often be responsible for being sure the submitted code corresponds to the documentation.  In either case, the issue will be finding the appropriate code for the case in question.  If the search for that code takes an inordinate amount of time, care will be compromised when a physician has to direct attention away from patients to search for an ICD-10 item.  If it is a coder, the efficiency of coding operations will be diminished, and in many cases, more coders will thus be needed. As the cost of physicians and coders is non-zero,  such anticipated new inefficiencies can be expected to be expensive.  Hence the cost of care is quite likely to be adversely impacted.  “Affordable,” you see, exists at present in the eyes of the beholder, but not necessarily in the eyes of the one writing the check, whether it bounces or not.

            So we were trying to see how well the CMS code-lookup tool worked, and to ascertain what insights into the mind of ICD-10’s creators, we could obtain.  We recommend that each of you try this out.  The web-link is below3, or you can Google ICD-10 code lookup. Once there, ICD-10’s fun and complexity begin to be revealed. Moreover, it is clear that CMS did not hire a Google-trained developer to create its search engine.  The basic elements of good search are missing.  This one small oversight will cost millions.  A good search engine needs to have certain basic elements. For example, if you type in either cars or car in Google, you will get a search not unlike that if you type in auto.  That is, the search engine “knows” what items are identical or nearly related. This basic component affords compatibility with users, also known as humans, also known to be imperfect.  In medicine, no less does such flexibility need to be present in search engines.  But no!  The CMS ICD-10 search engine requires extreme specificity in keywords.  We wanted to see codes for an aortic dissection.  Entering “aortic dissection” gets you nowhere.  Entering aorta dissection is required. Unlimited examples can be obtained if you try it yourself.

            Therefore, if you are the one who has to put in the right ICD-10 code—good luck. But since neither luck, nor CMS fixes, are items to be banked upon, we suggest you create a “cheat sheet” of keywords to expedite the process. Post it, and have therein the common items that are used in your care setting.  Classic provider diagnosis is totally inconsistent in the ICD-10 lexicon.

Examples (try them):

1.    Acute Myocardial Infarction (does not exist as an independent entity; lised in search results are comorbidities only).

2.    Myocardial infarction (returns subsets, but lord help you if you put in acute)
a.    NSTEMI (works)
b.    STEMI also (works - with subsets for anatomical and arterial sites, if known)

3.    Unstable angina (works – but if you specify beyond 120.0, you are into transplantation and bypass graft sequelae)
a.    If you use the keyword angina- ICD-10 gives you a list of 30. Have fun reading.

4.    Pneumonia – (oh boy…you get 100 to chose from)
a.    If you put in community acquired pneumonia – nothing
b.    Hospital acquired pneumonia - nothing
c.    Better have your billing company tell you which one to select

5.    Acute Bronchitis—(works –kinda – get a list of 11,  nine of which you need to specify the organism, and the other two are organism unspecified and neither acute nor chronic). Having fun yet.
a.    Bronchitis alone expands the list
b.    The last of these is J68.0 (Bronchitis and pneumonia due to chemicals, gases, fumes, and vapors).  And if you search, then, inhalation, you get a series that begins with J69.0 (but not J68.0). You must be having fun at this point.

6.    Pharyngitis – (sort of works –the things we see all the time, e.g. early congenital syphilitic pharyngitis come to the top of the list….while those that are comparatively rare, like strep pharyngitis or acute pharyngitis, unspecified are further on down).

7.    Finally: as a final example (among many, many possibilities) of what is going to be frustrating, if you put in pulmonary embolism you get a list of six codes, none of which apply to a case of acute pulmonary embolism. If you put in pulmonary embolus, you get two codes for saddle embolus with or without cor pulmonale.  And finally if you put in just embolism, you get a goldmine (!), but it is longer than Tolstoy’s War and Peace.  At that point, I tried lung embolism and got “There are no ICD-10 Codes that match.”

Oh brother, this will be a slow process with a great deal of frustration. If readers send in their most common, basic diagnosis list with and ICD-10 equivalent, we will try to create a spreadsheet for common usage.  Keep in mind, too, that selected codes must correspond to the correct code assignment (in the ICD-10 CM/PCS).  Otherwise appropriate reimbursement for any clinical entity billed to a payor/insurance company may likely not occur.


1. Countdown & Overview:

2. Provider Resources:

3. Code Lookup

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XpressTechnologies practice management, billing and Electronic Health Record are ICD-10 ready and compliant and will provide any assistance in this major transition.