Disposition Driven Test Ordering/A Change in Paradigm

The most common complaints about Emergency Care is cost and inappropriate utilization.

The Sensible Test Ordering Practice in an Emergency Department report was published by a pathology magazine, and provides the STOP methodology to reduce the # of coagulation and glucose testing most of which do not affect outcome and or treatment. A major problem seen from the viewpoint of these authors in the lab (pathologists) is the classic rationale for test ordering, which consists of ordering packages of tests that (if negative) do not affect outcome. Ordinarily this happens for the sake of consultants, completeness, diagnostic uncertainty, usual practice, training dogma, and liability concerns.

Analyses of this sort don’t get the principles that truly apply in emergency medicine, and those principles are based fundamentally in clinical judgment.  Is it the responsibility of the ED doc to save money, or potentially save the life and health of the patient?  When standing in the pathology lab, any negative test appears to have been unnecessary. 

On initial presentation, the ED doc is confronted with a unique chance to impact the care of any patient.  If he/she has seen a hundred patients and cast the “wide net” of a “routine” set of lab tests, receiving, say one or two with a positive result that impacted life, but 98% or 99% are unnecessary, is this type of pathologist’s perspective really of value?  Ask the patients who were impacted.  No wonder that getting out of the “routine order mindset” is a daunting task. The article shows how difficult and complex getting rid of a “low hanging fruit” test is. Low hanging fruit is fruit because sometimes, just enough times maybe, it makes a difference. But is testing practice really a result of mindless habit?  Or could it be experience and concern for the patient driving such testing?

It would be “politically correct” to suggest that the Emergency Department Provider change focus and order only tests that directly affect patient safety and disposition. How realistic is that?  In truth the ED doc, when first seeing a patient stands at the gate of a large city, looking for a place to live.  Since real estate is specific, finding the one that fits requires casting a larger net than other providers do.  Of course, understanding red flags and high-risk situations can deliver the provider to a quick risk assessment of most problems. But not every important flag is red, nor are all situations high-risk today, that will become high-risk tomorrow. Ask any plaintiffs lawyer. Then factor in the true cost of limiting testing from the pathology suite.

While the provider might be counseled to focus on the 1 or 2 tests that clinch the diagnosis, determine the disposition, and send the patient down the proper pathway to health, this paradigm ignores entirely the patient whose disease process would be found through other testes.  And certainly, limiting tests to the “money tests” will decrease costs on the set of patients for whom they are limited, but not for the system in which misses will naturally increase. 

An example of a restricted test protocol would be:

The provider would be given:

1. the vital signs with pulse oximetry
2. EKG if indicated
3. The option to order 1 or 2 tests maximum
4. Upon receiving the results of those tests the provider can discharge, admit, start treatment protocols.
5. If the patient is critically ill or immediately falls into a specific treatment protocol, these can be initiated. The treatment protocols include all the tests anybody would want.
6. Time hopefully would be saved due to rapid disposition of the majority of patients who were concerned about very specific problems.
7. Likely however, time will be lost in total because there will be significant number of doctor-patient combinations where sufficiently clarified status is not obtained by limited testing, and repeat, after repeat, after repeat keeps the patient there for hours (and hours, and hours)
8. On the one hand, when successful, down-stream costs with endless consultations may be avoided. On the other, the costs will HUGELY accelerated in those cases missed.
9. The ED is a unique opportunity, especially for the many who have no other access to care.

Examples:

1. Patient has chest pain. EKG + for Acute MI. Disposition would cath lab and MI protocol. (The authors would not check the INR, if the patient is on warfarin, and if the INR=50, that patient will likely not exit the Cath lab).
2. Patient has severe abdominal pain. CT-neg. Clinical reevaluation then discharge or admit. That would be fine if inter-observer reliability was present. It often is not (Br J Radiol. 2012 Sep; 85(1017):e596-602. doi: 10.1259/bjr/95400367.)
3. Patient has head injury. CT-neg.  Clinical reevaluation and disposition. (but you missed the leaking aneurysm)
4. Patient has sore throat.   Treat.  Reevaluate if no improvement. (Did you catch the epiglottitis?)
5. Patient has severe cough and fever. CXR-right lower lobe infiltrate. Reevaluate clinically and discharge with appropriate prescription or admit with pneumonia protocol. (ah…yes, forgot the CT scan, and the patient returns dead after multiple pulmonary emboli)
6. Patient with weakness. EKG shows u-waves. Get electrolyte package and treat. (ah sure, treat for hypokalemia, but did you remember that u-waves can be sign in subarachnoid or intra-cerebral hemorrhage)
7. Patient with low-risk chest pain. Troponin-neg, EKG normal. Repeat troponin 2 hours. Make disposition. (that’s the one whose pericarditis you missed because you did not do a CXR)
8. Patient with possible stroke. Depending on distribution of symptoms get MRI or CT. Start treatment protocols if indicated (don’t forget the coag profile!)
9. One of the most important clinical tools one can develop happens when one makes oneself record (write-down) the results anticipated for any test. This was taught to one of us by an illustrious grandfather of medicine shortly before he died.  The lesson was that by doing so throughout a career, dependency on tests would decrease. One’s clinical insight would gradually increase, and the path to a correct diagnosis would be much quicker.  It works. And it is a much better approach than simply STOPing the test net.
10. The approaches suggested from the pathologist Labe are intended to save a lot of upfront costs, admissions, and hopefully downstream costs. Do they really save time???  Save lives, save morbidity? Theoretically they should. But the misses are simply left out of the picture. And those have extreme costs to both the patient, the doctor, and the system.  Bottom line: take the time to hit a “home run” rather than run the count to 3 balls, 2 strikes on each patient before making a disposition. Home runs require hitting all the bases, you know.

The Beach Boys - I Get Around - Workarounds

In the recent article Targeting EHR Workarounds, the author makes the following comments: Workarounds, depending on the system and the user, might be harmless in some cases but potentially dangerous in others.

 

Whatis.com states the definition: A workaround is a method, sometimes used temporarily, for achieving a task or goal when the usual or planned method isn't working. In information technology, a workaround is often used to overcome hardware, programming, or communication problems.

The fundamental problem is that these workarounds may solve problems, but may inadvertently create hidden/unknown downstream issues.

1.      Potentially created by a non-authorized user, circumventing safeguards
2.      Putting the facility, the user, and the supervising hierarchy at liability risk
3.      Affecting data collection
4.      Missing financial credit for the documentation
5.      Missing data qualifying for “meaningful use” credit
6.      Potentially using macros with cut and paste that obscure the individuality of the encounter
7.      Potential fraud issues as to what discussions and acts were actually performed.
8.      Very important: avoiding definitive resolution of the issue. That is, by taking the workaround short-cut, and not communicating with the vendor about the problem (sometimes easier said than done), it will continue to appear for everyone.
9.      Customization may be creative but cost-prohibitive.
10.  ETC.

Many workarounds are designed to avoid alert fatigue. These may do the job most (99%) of the time but can be disastrous if key information happens to be ignored at a crucial time. See our prior blog on “Alert Fatigue”.  For example, scanning-in of relevant documents (say, a medication list) may make life apparently simpler, but if physician eyes do not see a key item (e.g. warfarin) the EH R and its decision support mechanisms will be missing critical data (so, the patient may bleed to death if sent to surgery without anticoagulant reversal).

 

Workarounds are most often created by the most innovative and intelligent clinicians among us (and the ED seems to have it share of them), trying to overcome tedious workflow issues in their E H R.  Many are guilty of discovering and using them. No names will be given. Unfortunately, however, the problems noted above can (and have) come back to haunt the provider and the facility. The best solution is find an EHR designed specifically for your area of work and engage the vendor in a continuous process of making the product more user-friendly. In that way, workarounds can quickly become a principle source of EHR and workflow improvement. “Workaround types” would enjoy listening to the Beach Boys classic –I Get Around.

Which is Worse? Malpractice Case or Medical Board Investigation

The Black Cloud of a Medical Board Investigation is a must read for practicing professionals. The title speaks for itself. A referral to the medical board of your state can turn into a complex nightmare scenario in which you can be viewed as guilty until proven innocent.

To limit damages, targeted providers are forced to hire lawyers at their own expense to hopefully limit damages. Even though most cases are resolved quickly, even these can easily cost $20,000 and up in legal fees. In our experience, medical board actions have been as costly, as high a career risk, and as stressful as a malpractice suit.

The cases that go “south” can lead to summary suspension of license, difficulty in obtaining malpractice insurance, getting on certain insurance plans, dismissal from a hospital staff, and getting a “strike” in a 3 strike (3 strikes and your out) state like Florida.

Unfortunately, complaints are easy to file. The accessibility of filing by everyday individuals has made these actions much more common than malpractice suits. To make matters worse, accusations can morph over time and can be resubmitted multiple times if a patient or family does not get their desired result.

Medical boards receive many different kinds of complaints. Some are extremely serious (see below) but it has been found that most board actions are a result of poor communication and poor interpersonal relationships.

The most serious kind are designated sentinel events. According to the Joint Commission, a sentinel event is “and unexpected occurrence involving death or serious physical or psychological injury, or risk thereof.”  They are called sentinel because “they signal the need for immediate investigation and response. 

Ordinarily, these types of incidents get reported to the Medical Board by the critical incident committee of the hospital.  Although relatively minor events can qualify as sentinel, more frequently they are about major events and wind up being appropriately referred from the hospital to the board.  A significant proportion of these complaints are initiated by unhappy families who want “whatever they perceive has happened to their relative never to happen again”. Those who work with such cases know that perception and reality are not always identical in many situations.

While most providers are understandably paranoid about malpractice and/or liability issues, they nevertheless need to educate themselves about medical board practices in their states.  The potential adverse effects of a board investigation are not to be taken lightly. Both type of incidents, malpractice allegation and medical board referrals, are serious events that can be life-changing. Hire appropriate experienced counsel to help you survive the process.

Good patient communication, positive interpersonal relationship, and excellent documentation will help prevent both malpractice claims and board referrals. Good documentation does not have to lengthy, but when it is goal specific and captures the essence of clinical interactions, it can be life-saving (and career-saving) if confronted with either type of incident.

Meaningful Use- Rise of the “Best of Breed”?????

Is the “Meaningful Use” financial incentive actually going to end? According to article CMS Promises Meaningful Use Replacement This Year significant changes in the program will be implemented in 2016 and possibly be in effect by 2019. The goal is a more “patient-centered” output and not endless data collection.

Meaning full use was defined by the government to be

1. The use of a certified EHR in a meaningful manner.
2. The electronic exchange of health information to improve quality of health care.
3. Stimulate the adoption of EHR through financial incentives for using (e.g. not let it sit in the corner) certified EHR technology for defined elements of clinical care.

After 32 Billion Dollars expenditure in incentive money, we have a dysfunctional, non-intraoperative, and user-unfriendly national conglomeration of systems that just can’t communicate with one another.  Sounds a bit like Congress, does it not? The outcome probably should not be called a system because every product is somewhat unique and the stated goal of being able to trade information between facilities (interoperability) is no closer than it was in 2004 when then-President GW Bush put the federal government into the electronic record business.

Now, CMS has reset its sights, deciding that the new goal is not to promote adoption of EHR technology, but to pay providers for (good) outcomes that result from using such systems.  This paradigm, in CMS mind, is to replace the fee-for service paradigm. Of course! Why not!  For example, someone arrives in ventricular fibrillation and you pull out all stops to try to get the heart beating synchronously again.  Shock after shock fails.  Drugs fail. Everything fails. The patient succumbs. The outcome:  well, it is no-so-good. But you do not get paid for the powerhouse effort that you are describing on the EH R record.  No.  You write that the patient was transferred to the morgue.  Hence, the outcome deserves zero reimbursement.  Certainly much less than I you had restored cardiac rhythm and transferred to the CCU, before the patient died, and then was transferred to the morgue. Make sense?  Maybe CMS will convince hospitals to keep investing in better equipment, at least so it is ready one of the CMS administrators show up in v-fib.  Or maybe they will not, and the outcome will be vfb à morgue. 

Now, how this will be done will be interesting to watch. It will be quite challenging because certain specialties provide isolated real-time care while the traditional life-long practice provides longitudinal care. For most of the latter, the patient is still present when outcome is determined. The reconciliation of these different, and somewhat competing, paradigms will be difficult to achieve.

The Electronic Health Record, so often written about in many of our prior blogs, will need to change its fundamental character.  An emphasis on creating legally defensible documents, and an emphasis on an EHR use as a billing tool, will both be expected to come in secondary to its use as a patient-centered tool.

It’ll be nice if it works.  No skeptics here, right?  Yet, the coming evolution of the EHR may present great opportunities for focused or “Best of Breed” electronic health records that handle specific medical areas of expertise. Yes, enterprise systems will continue, but they may be constructed as user specific modules (apps) to accomplish these new goals. Think of your cell phone. These systems will have to allow “plug and play” programs or specific “apps” to give the providers the necessary support to be efficient and financially successful.

Why Do Certain Electronic Health Record Installations Fail?

The article Denver Health CIO, COO quit, blame pricey Epic EHR installation, says Denver Health Medical Center (where Dr. Kamens and I trained during our early EM careers) our alma mater had considerable financial and personnel problems during their Electronic Health Record installation. As one might expect, the vendor and the hospital had different versions of what actually happened. Lots of finger-pointing ensued.

Implementation problems of this type may be caused by locally specific factors, but are not unusual throughout the EHR industry, and appear in diverse locations. Finding out (and revealing!) what those fundamental issues were would be a great help to other institutions and vendors.  Unfortunately scenarios of installation blunders are only rarely shared outside the vendor’s office, and we are left doomed to repeat history from which all could have learned.

In the old days (circa 1970’s-80’s) it was common to attend a hospital educational programs called M & M conferences. The New England Journal weekly case discussion at Mass General was a paradigm for many through which medical prowess could be advanced.  M & M stood for Morbidity and mortality. Wikipedia notes:

“M&M conferences “are traditional, recurring conferences held by medical services at academic medical centers, most large private medical and surgical practices, and other medical centers. They are usually peer reviews of mistakes occurring during the care of patients. The objectives of a well-run M&M conference are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications.^[1] Conferences are non-punitive and focus on the goal of improved patient care. The proceedings are generally kept confidential by law.^[2]M&M conferences occur with regular frequency, often weekly, biweekly or monthly, and highlight recent cases and identify areas of improvement for clinicians involved in the case. They are also important for identifying systems issues (e.g., outdated policies, changes in patient identification procedures, arithmetic errors, etc.) which affect patient care.^{[1][3]  “}

In the purely clinical realm, perhaps due to present liability issues, M & M’s may not be as forthright as in the past. For certain, every intern and resident dreaded to be on the podium at one of these events.  “And what were you thinking at that point, Dr. Ausgiblinken?  Today, it is likely that the extent of dread probably includes most staff, physicians, attending, and others. After all someone has to take the blame when things go south.

Knowing an implementation is coming up is a common cause for major anxiety too. Can we do anything about the fact that many doctors, nurses, other providers, and administrators shake in their boots when a new installation is on the calendar? Wouldn’t it be nice if they could be at least as relaxed and as confident as when about to have a colonoscopy? That should not be such a distant dream.  Really.  Nobody puts the clinical, IT, and administrative teams into Sims or Trendelenburg. But to look at their faces the week before the new system arrives, you wouldn’t know it. 

Could we have M & M conferences for EHR implementations, sharing analyses of the good as well as the bad?  Publically available, they could vastly improve implementations, avoid common failures, and create an important knowledge base. Such M and M reviews would be welcome tools from which to learn about what really happened and what problems could have been avoided.

One might discern whether problems encountered were:

1. Systemic
2. Caused by individuals, particular departments, or departmental relationship
3. Resulted from lack of buy-in by the providers
4. A result of insufficient training
5. Caused by Hardware and/or software issues
6. Plagued by Usability issues
7. Due to an absence of effective leadership
8. Arose from a combination of two or more of the above
9. Etc.

Data gleaned from such open discussion would certainly help all institutions and vendors. Become more effective at EH R implantation, for the overall benefit of patients, and healthcare delivery.