Monday, January 25, 2016

Opioid-Free Emergency Departments-Would You Go There?

In the article Opioid-Free ED: Coming Soon to a Hospital Near You, the author makes a case for an Opioid-Free Emergency Department. His concerns were for the potential drug abuse through narcotic prescription writing and eliminating a percentage of patients who are drug seeking.
He offers a table for alternative treatments.
Table. Non-opioid Alternatives for Pain Management



Renal colic

acetaminophen, indomethacin, ketorolac, lidocaine, rectal indomethacin

Back pain

acetaminophen, diazepam, ibuprofen, lidocaine patch, methocarbamol, trigger-point myofascial injections


diphenhydramine, ketorolac, metoclopramide, prochlorperazine, sumatriptan,

Musculoskeletal pain

acetaminophen, ibuprofen, lidocaine patch, naproxen, nitrous oxide, regional nerve blocks

Neuropathic pain

clonidine, gabapentin, ibuprofen, nortriptyline, pregabalin


acetaminophen, bupivacaine, ibuprofen, naproxen, nitrous oxide

Sickle cell crisis

hydroxyurea, ibuprofen, ketamine, nitrous oxide

Chronic pain

gabapentin, ibuprofen, lidocaine patch, prednisone, trigger-point injections

Pediatric pain

acetaminophen, ibuprofen, ketamine, nitrous oxide

Regarding this opioid-free approach, we have an alternative point of view; and it is backed by years of experience and success with narcotic-based analgesia when properly used.

There are certain conditions that narcotics definitively benefit, especially in their acute phases. Consider heart attacks, severe visceral (abdominal) pain, multiple injuries, fractures, ruptured disks, intubation & procedural sedation, sickle cell, cancer patients, etc., etc. Do you really want to practice without morphine or its derivatives as options?

Narcotics are easily titrated with proper protocols and PCA (patient-controlled analgesia) pumps. Most studies show that pain (as a presenting or prominent symptom) is the #1 or #2 reason for going to the Emergency Department.  Not uncommonly, once seen, it is undertreated.

What can be done? Balance is needed in clinical emergency medicine, and with care, a common sense practical approach can be reached. During any one patient encounter, the ED clinician should not impede his/her decision-making process by deliberating political correctness or evoking concern for the vast social ills that abound in the culture.  These are surely not the priority of the patient in front you, and so they should not be yours either, at least not during the encounter. Helpful failsafe protocols can capture some offenders, and some issues, but they are not perfect.  For example, refills can be limited or non-existent; a statewide or local e-prescribing history can limit repeat prescriptions to prior offenders without verification..

The bottom line: treat pain. Treat it strongly.  It is one of few things we can reliably do for people. (Yes, there are others, but the list of interventions that really make a perceptible difference is shorter than we would like it to be).  Remember the last patient you relieved of pain, and keep that image in mind. And if a member of my family is in desperate pain, please take care of them. Mo-phine would be just fine.

Monday, January 18, 2016

Being Honest about Electronic Health Record Costs

In the article Hospitals face budget woes with switch to electronic records, Brigham and Women’s, one of the most famous and profitable hospitals in the USA, lost money in their transition to an Electronic Health Record.

The article is interesting and hospital administrators should pay attention.

            The Electronic Health Record is potentially a great tool when built and used properly. These advantages have a steep price tab when all aspects are factored in.
  1. Cost of system (including hardware and software)
  2. Cost of ongoing Support
  3. Data storage (consider HIPPA compliance)
  4. Training
  5. Repeat Training
  6. Learning curves
  7. Difficult user interfaces, frequent updates. These require re-learning and workflow readjustments that are seriously expensive. 
  8. Costs of customization
  9. Hiring more personnel
  10. Getting providers to cooperate
  11. Keeping EHR costs within rising clinic and physician budgets.
  12. Matching the right diagnosis codes, right diagnosis, and accurate documentation.
  13. Over-coding and under-coding
  14. Charts that are written in “computer-eeze”.
  15. The additional costs of needed modules.  For example: Voice Activated Technology and/or other programs make enterprise systems more user friendly (sometimes).
  16. Malpractice worries with mega-data
  17. HIPPA concerns
  18. Computers and programs can be used to help solve problems but they do not accomplish this “magically”.
  19. Volumes of incoherent data collected
  20. Burn-out of the staff and providers
  21. ETC.

A great many such costs are hidden. We see a good number of task forces created to improve efficiency.  Often they accomplish that goal by jury-rigging work-arounds that only last as long as the task force. A year goes by, and the facility is back to ground zero.

Bottom line, the EHR is a tool; it is not a global solution.  Hence EHRs should be customized to meet the clinical needs of the providers and staff, first. The wishes of the accounting department can be addressed after all the patients are cared for.  

Monday, January 11, 2016

Usability and the Future of the EHR

Many articles have been written correlating the weakness of  EHR usability and patient safety.  As a physician and EHR user, here are some key points that an EHR of the future, and the healthcare IT environment in which it lives, should address and push for.

1. A NATIONAL DATABASE: Creation of a national healthcare database with the intent of including every individual, with records presented via a standardized format.
a.Yes, this is a bit far off, and there are obstacles. However, we feel this goal is so key that planning and development now should take into account the needed sub-steps along the way, for its achievement. Otherwise, we will continue to be untangling spaghetti for eons.
b. Such a central database would streamline access to health information for every patient interacting with any Electronic Health Record in the country.  While the term "interoperability" is frequently tossed around, the fundamental point of interoperability is ability to easily share information. Central storage is not really necessary, but centralized access is.
b. Direct incentive-type funding.  Meaningful use was an understandable first effort. But putting huge incentives into time and work consuming data collection queries, has made providers suffer, with little benefit. When a national database is available, information can be more easily examined to determine how EHRs are being used in identifiably meaningful ways. 
c. Movement in this direction would be like putting the money in the bank.  As it became established, it would be a fundamental and available resource.
2. STANDARDIZATION OF CPOE: Creation of a standardized national Computerized Order Entry (CPOE) system with its user interface replicated at every care-site care would generate huge improvements in safety and efficiency. Modifiable order sets for key presentations could be built and maintained by specialty/sub- specialty authorities, and adjusted to meet local needs. 
a.  This would represent a significant advance, allowing providers of all stripes to interact with local systems when directing care, without endless learning curves.
b. Optimally, the entire staff should be able to use the system rather than the highest paid providers being the data input clerks. Various levels of authority would allow hierarchical verification and acknowledgement of orders, promote safety, discussion of clinical course, and appropriate supervision of ordering.
c. One would expect that developed orders would be care-setting specific (modular) and provide the most common orders in easy array of choices.
d. Order interaction with the pharmacy should also be care-setting specific i.e Emergency Department, operating room etc. Moreover, prescriptions/e-prescribing should be care-setting, care-track, and provider specific.
e. Simplification could be globally anticipated. For example calculators (such as pediatric dosing, and other weight/age based therapies) could be straight-forward and easy to use (see the local ATM)

3. INTELLIGENT CLINICAL DECISION SUPPORT: It is time for research to progress in the realm of clinical decision support. Artificial Intelligence is making its way into the world (think Siri), and medicine should not be behind in this exploration. 
a.  A real potential benefit of an EHR in clinical care is in the promise of AI. Right now, most of the research needed on any one case is still on our shoulders. Who of us does not do a google search or explore a reliable source (like "Up-to-Date") on a frequent basis to support of clinical decisions.  The butler (Siri's colleague) can help do that for us. 
b. A good system ought to be aware of your needs, even before you are conscious of them.  Should not a differential diagnosis be automatically generated from the information within your CC, HPI?  If the computer recognizes certain symptom complexes, the provider is supplied can be given easy access to information, treatment protocols, policy recommendations, and appropriate reminders to consider key diagnostic options.
c. Also included should be medication alerts that indicate potential severity of pharmaceutical choice and dose.
4.   SIMPLIFICATION: in the design, construction, and implementation of the actual EHR. For example:
a. Make nursing notes, provider notes, labs, x-ray reports, etc. accessible without having to go to multiple screens to find them.  This is technology available now.  Tabs, mouse-overs, and other tools should be fully implemented in the EHR space. (Google News is a good example of a summary presentation that includes all potentially important items)
b. Artificial intelligence/decision support suggestions should appear in a way that supports the provider’s ability to look over and collate all the data.
c. Another example exists in the sometimes disparate modules that comprise an enterprise EHR.  Direct interaction between the EHR and the tracking board is essential to assist providers and caregivers in controlling a flood of information and prioritizing decision making. Why put information in twice, three times, or more?
These are just a few suggestions. Please add your own below. Let's help make the record a real-time clinical assistant instead of just a medical-legal document and a billing tool for reimbursement.

Wednesday, January 6, 2016

Real-Time Artificial Intelligence Utility

Artificial intelligence (AI) is defined by Wikipedia as intelligence exhibited by machines or software. In the article 10 Ways Artificial Intelligence Could Make Me a Better Doctor, the author lists 10 ways to take advantage of AI support. Number 6 on the list is:  “Help me make hard decisions rational.”

The others are worth reading but are more related to time management aspects of practice. Being guided toward trustworthy, intelligent, rational decisions based on up-to-data, practice guidelines, and cost consciousness would help most any clinician. After all, there is already doing this processing in their gray matter.

Here are some practical areas in which a well-functioning EHR-AI (Electronic Health Record Artificial Intelligence) system could effectively support providers in making timely good clinical decisions

1.     Creating an easily understood differential diagnosis hierarchy
a.   It would be quite helpful if the AI used incoming clinical data to create a hierarchical differential diagnosis tree (perhaps graphic) based on likelihood and potential risk. The AI could supplement the clinician’s differential diagnosis, and create a high-risk profile, with alerts, individualized for each patient.

2.     Fully probe the Differential Diagnosis
a.   For example, if a pulmonary embolism is considered, the AI could risk stratify the patient using clinical scoring schemes. It may ask the provider for more data, and could give the provider instant access to relevant clinical articles and best practice guidelines.
b.   It could then make recommendations regarding the work-up needed.
c.   It could provide real-time cost data for any testing.

3.     Developing a treatment plan
a.   The AI system would most commonly offer established treatment protocols
b.   It would show time frames, when treatment is time critical
c.   It might offer alternatives if patient refuses
d.   And it might also give guidance on shared-decision making data

4.     Selecting appropriate medications
a.   AI could use tailored real-time displays to signal:
     i.     Significant clinical side effects
     ii.    Allergies
     iii.    Drug-drug interactions
     iv.    Cost analysis
     v.    Data supporting alternative (non-pharmaceutical) treatment

5.     Disposition Analysis:
a.   At time of disposition, the high-level AI system could address key areas to remind about needed attention:
b.   Scan the final-stage record to be sure no key oversights exist
c.   Flag and display any unaddressed high-risk warnings
d.   Verify prescribed follow-up times
e.   Recommend consultants, primary physicians and/or others

Most clinicians already do all these things with each patient. The AI, if functioning expediently, would function as another “eye” on the case. Quality of care should improve, and perhaps come closer to its higher potential.

No, an AI system will never replace flesh-and-bones clinicians, but it has the possibility of greatly augmenting their performance capacity.  If these clinical decision support systems appear on the market, and are well build, acquiring
one for a busy practice would be a no-brainer.