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).

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.

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.

The Perils of Alert Fatigue

The authors of Alert Fatigue analyze and define the term as "...how 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. 

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.