Monday, April 25, 2016

Clinical Decision Support to Alleviate “Misdiagnosis”

The Institute of Medicine found that “most people will suffer from at least one wrong or delayed medical diagnosis during their lifetime, according to the latest data. Americans experience about 12 million diagnostic errors a year.”

“Conservatively, the report found that 5 percent of US adults who seek outpatient care will experience a diagnostic error. Further, such errors are thought to contribute to 10 percent of patient deaths and 17 percent of adverse events in hospitals.”

In the article Is Misdiagnosis Inevitable, the reality of misdiagnosis is discussed with potential solutions through clinical decision support from Electronic Health Records.

Unfortunately, the term misdiagnosis is misused to include everything under the sun. It neglects the concepts of over-diagnosis, overtreatment, irrelevant diagnosis, and mostly that people the majority of the time get better without treatment. “Tincture of Time” solves most problems while potential erroneous treatment plans can pose harm and drive the Medical-Industrial Complex to more and more.

Assuming that the missed diagnosis has clinical relevance (affects patients not statistics) , it would be important to reduce these errors.

Common factors causing problems are poor communication, inexperience of the various providers (providers is now generic for physicians, nurse practitioners , Physician assistants, and all other medical providers), pressure to see patients in a strict timeframe, minimizing test ordering, and finally unfortunately poor cognitive distillation of the present information by allowing acute on chronic biases to cloud judgement.

The IOM’s 1999 report said to “To Err Was Human”. Human beings probably have not evolved significantly since 1999 to fantasize that errors will not be made. The goal should be to limit critical errors by avoiding common recurrent mistakes.

The well-known ones are illegibility, allergic reaction, drug-drug interactions, lack of follow-up on abnormal tests that were ordered by someone, and systemic errors that create pressure to perform in unsafe environments. Consumerism and the public’s fantasy that everything can be figured out in 24 hours or less are also factors.

With respect to malpractice litigation, the acceptable miss rate on a patient in the United States is 0%. This cannot be achieved without endless unnecessary tests that may lead to unnecessary treatments that leave the patient in worse shape than the initial error.

One must remember that the concept of diagnosis itself derives from the diagnostic medical model:  symptomsà examination/testing à diagnosis à diagnosis-based treatment.  There are inherent flaws in that model, especially as the field of potential diagnostic entities grows in its complexity and possibilities.  Consider immunotherapy for carcinomas.  There, the diagnostic possibilities have expanded exponentially because of nuances in genome delineation. Many other subspecialties are following, each entity with its own specific therapeutic modality, and each with its own heavy price-tag.

What has (surprisingly) never been fully incorporated into the emergency medicine diagnostic model is the impact of time and extended clinical relationships.  That is, we discharge patients with a “diagnosis” which is not-uncommonly some vague re-interpretation of symptoms (e.g. “back pain,” “dizziness, vertigo”).  And the best outcome diagnostically, for us, is admission.  Why? Because, then the admitting physician is responsible for discovering the true nature of the disorder.  The next tier of outcome is arranged follow-up, in which a referral physician agrees to see the patient and continue the care as needed. A sub-tier to that is the more unreliable diagnostic plan of “return if worse” or better “return for a recheck” at a specified time. Finally there is the common discharge plan for diagnostic security:  “see your doctor if worse.” 

The experienced physician accepts that his diagnostic acumen is sometimes on, sometimes off target, and so builds a measure of time into diagnostic equation.  If done well, there is no such thing as misdiagnosis, there are potential diagnoses, there are working diagnosis, but there is no “final” diagnosis until confirmed by time and further evaluation.

What can be done to align these competing forces to allow the “lonely practitioner” to get the diagnosis right? Perhaps creating clinical decision support (CDS) tools in the Electronic Health Record through artificial intelligence (AI) may help. Effective employment of this may be a decade away, and may require buy-in from the tech industry, which seems decades ahead. As one ED physician recently said to his enterprise system that was trying to speak to him: “shut up…’re no Siri.” When present, good AI will hopefully function as a real-time consultant to the provider with propositions for differential diagnoses, treatment plans, legitimate warnings, notifications that the data inputted may suggest another serious diagnosis, the tests you never looked at are on page 21, and the nursing notes show major discrepancies with the provider’s input.

Bottom line, the system presently works quite well but can be significantly improved. Misdiagnosis should be a term only applied to situations that cause real harm to an actual patient, and only if the full-force of diagnostic acumen (and time) has been applied.  Accomplishing non-misdiagnosis is difficult in our current system, of course.  But thankfully most cases usually takes care of themselves. Preventive care actually may be the long term solution for serious all-to-common self-inflicted illnesses. If, that is, you can get patient buy-in.

Monday, April 18, 2016

Allowing the Patient to Input Data into the Electronic Health Record

In the article Medicine 3.0 Panelists Dissect Patient-Generated Data, a group discussed the possibility of the patient inputting their own data into the Electronic Health Record. These included objective data like blood glucose measurements, virtual assistant type tasks, and changing the doctor-patient relationship paradigm from paternal (maternal) to dynamic.

With the multiple apps being constantly developed it is foreseeable that patients can arrive in the office or on skype with all the data necessary in advance for a focused practitioner-patient interaction. Rather than let’s get an EKG; the EKG is already completed. This can affect all the blood work dramatically. This will dramatically save the patients time and expense.
The virtual assistant tasks are even more intriguing. The patient can be offered a problem-specific template to be filled out that asks all the pertinent data. The provider can quickly review and affirm the accuracy and quality of the data. They can then ask problem specific questions to solidify the diagnosis. Can patients answer these questions? They do now but verbally. They can also be asked about the research they have already done on the internet. If they cannot fill out the forms than office staff can call in advance and verify items like problem lists, medications, and allergies.

The last concern was the patient-provider relationship change. The consumer wants timely accurate answers, compassion, and to get the provider’s expertise. The paradigm of rushing through multiple questions that usually have been already asked several times already could become a thoughtful interaction.

Two big unaddressed issues here are privacy and doctor time.  Privacy can no longer be secured, as evidenced by recent ransom-ware break-ns. The potential for hacking into a system goes along with having a system. Patients, at this point need to be informed that a facility will do everything possible to provide IT security, but cannot guarantee it.  It a patient types information into a system where security has been guaranteed, and it is hacked, the facility can wind up on the adverse side of a courtroom.

And then there is our old friend, time. How many doctors do you know (maybe you?) that really have the time to read all their patients’ blah-blah-blah.  True there is important information potentially there, but a downside will be that many patients will have free-hand at the keyboard, and take it.  Then what?

In conclusion: Look for major changes in workflow and data collection in the near future. This can be a positive development. Compliance may be improved and not understanding what the provider said may diminish.

Monday, April 11, 2016

Improving Quality with the Use of the Electronic Health Record

The following is part of a series covering the various aspects of the Electronic Health Record to improve patient care, quality, and satisfaction.
First in the series is CPOE (computerized provider order entry). The intended goal of CPOE was to provide a digital platform for entering and fulfilling physician orders, so that the streaming real-time data could be tested for errors.  The hope has been that common errors in the delivery of medical care could be picked up and addressed before dire consequences ensued. There are myriad examples but some that often bubble to the top include faulty transcription, suboptimal medication and test selection, drug-drug interactions, and inattention to allergies and other known risks individual patients report.  CPOE theoretically provides a milieu in which the order scheme being entered is tested against protocols for the same condition and against common but serious life threatening conditions that may arise. Wikipedia states:

Computerized Physician Order Entry (CPOE), sometimes referred to as Computerized Provider Order Entry or Computerized Provider Order Management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients. Basically this acronym is a tautology, as order entry always requires some computerized facility.
[Not always, but most always.  There are still places that enter and submit orders on paper; some places still use tube transport systems.

Generally, the entered orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE decreases delay in

·         order distribution,

·         resource allocation,

·         order completion,

And shall
              ·         reduce errors related to handwriting or transcription,

·         allow order entry at the point of care or off-site,

·         provide error-checking for duplicate or incorrect doses or tests, and

·         simplify inventory and posting of charges.

As one can see CPOE was basically designed like a high-level accounting tool that to improve patient care through efficiency and error reduction. But…. the “devil’s in the details.”

From a provider point of view the following achievements would be great….

1.     Reduction in illegibility

2.     No more dosing errors,

3.     Selecting the right treatment plan.

4.     Selecting the most cost-effective treatment plan without sacrificing quality

5.     Protocols that are “state of the art” by evidence-based medicine.

6.     Warnings when a mistake or allergy is perceived.

7.     Guidance by artificial intelligence to make better decisions

Problems arise, and the following phrases might be heard:.

1.     Why does a provider (me) have to do data input?

2.     That’s the eighth warning alert this hour!!

3.     How do I change an order?

4.     Wasn’t that protocol changed last week?

5.     I can’t figure out the pediatric dose calculator without my slide-rule. I give up.

6.     Why are cancer protocols mixed in with the Emergency Department protocols?

7.     My favorites list is so long, that I seem to have everything I never use on it.

8.     How do I change a med on a protocol?

9.     How do I know that anyone saw this order without a verbal reminder?

10.   What is the average time delay between the STAT ORDER and it being followed?

11.   Do I really need to write a prescription to give 1 dose of medicine in the department?

The potential positives are obvious. Indeed, CPOE would be dramatically improved if

1.     Order entry was body-zone specific

2.     Order entry was specialty specific (system specific would do)

3.     The barrage of warnings and alerts was controlled

4.     CPOEs avoided lock-step control of the ordering physician, allowing flexibility

5.     Was streamlined, user-friendly, and therefore was not so time consuming.

6.     Permitted parallel artificial intelligence, curb-side opinions to cover your back.

7.     Standard user interfaces, so you’d would only have to learn CPOE once

8.     Showed cost estimates for each order

9.     Had available lists of indications for ordered tests and treatments?

10.            So truly user-friendly that assistants were never assigned to enter orders.

Perhaps in the distant future, after countless missteps and funding fiascos these features will be available.

Monday, April 4, 2016

20 Ways to Create More Time

Whether in active practice, or in retirement, identify activities with which you want to fill your days and hours. The following suggestions may help you to put these into practice, and are roughly based on the work of 19th-century Italian economist Vilfredo Pareto, the “Pareto principle.” It incorporates the observation that often 80% of results come from about 20% of the effort. Here is a simple example: When a carpet is vacuumed, about 80% of the dirt picked up is likely from 20% of the carpet, namely, the high-traffic areas. MOST OF THESE CAN BE APPLIED TO ONE’S HOME LIFE, BUT FOR THE ED, NOT SO MUCH. There are, however some that can be applied, perhaps with modification for our ED environment.

1 KEEP A DAILY TO-DO LIST. Number items according to the order in which you will handle them. Indicate items that are worth spending more time on. Check off each when it is completed. Carry over unfinished tasks to tomorrow’s list.

2 SYNCHRONIZE YOUR CALENDARS. Don’t risk missing an appointment because it is only in your other calendar. If you have a calendar in your computer and another in a handheld device, see if you can synchronize the two.

3 WRITE AN “ACTION PLAN” consisting of all the steps involved in a project, and put these in their proper sequence.

4 GENERALLY, SCHEDULE YOUR MOST IMPORTANT TASKS FIRST. Then, it’s easier to find time for less vital ones.

5 SET GOALS OVER WHICH YOU HAVE A LARGE DEGREE OF CONTROL. You have more control over increasing your skill at a certain job than over becoming president of your company.

6 ACKNOWLEDGE THAT YOU WILL NOT HAVE TIME FOR EVERYTHING. Favor activities that yield the most important results. What about other tasks that are urgent or that simply have to be done? If you cannot eliminate or delegate them, see if you can spend less time on them. Some unimportant tasks can wait for months if necessary, or they may not need to be done at all. Allocate as much time as possible to those activities that are related to what you feel is truly worthwhile in light of your goals.

7 KEEP A TIME LOG. To find out where your time is going, keep a time log for one or two weeks. Is much time lost on unimportant activities? Do most of your interruptions come from the same one or two individuals? Are you most likely to be interrupted during a certain part of the day or week? Eliminate time-wasting activities that have crept in.

8 SCHEDULE LESS. If you plan to shop for food, fix the car, entertain friends, see a movie, and catch up on reading—all in one day—you will feel rushed and will likely enjoy nothing.

9 MINIMIZE INTERRUPTIONS. Block off time each day in which you are not to be interrupted unless absolutely necessary. If possible, turn off your phone and always turn off electronic pop-up alerts that interrupt your work.


11 DO THE MOST UNPLEASANT TASK AS SOON AS POSSIBLE. Once it is out of the way, you will feel more energized to work through the less-challenging activities.

12 ALLOW TIME FOR THE UNEXPECTED. (the ED motto). If you think you’ll arrive somewhere in about 15 minutes, promise to be there within 25. If you believe an appointment will take an hour, allow 1 hour & 20 minutes. Leave a portion of your day unscheduled. Always remember:  tasks that you think will take 2 hours, always take 5, 7 or more.

13 USE TRANSITION TIME. Listen to the news or a recording while you shave. Read while waiting for a train or riding on it. Of course, you can use that time to relax. But don’t waste it and then later fret over lost time.

14 APPLY THE 80/20 RULE TO YOUR LIST, AND TO EACH TASK. Are 2 out of 10 items on your to-do list most important? Do them first.  Might a certain job feel less pressing if you give attention to just its most important aspects?

15 WHEN YOU FEEL OVERWHELMED WITH WORK, write each patient/task on an index card. Then divide the cards into two groups: “Action Now” and “Action Next.” Repeat and re-write as necessary.

16 PERIODICALLY, TAKE TIME OFF TO ‘RECHARGE YOUR BATTERIES.’ Returning to work with a refreshed mind and body might prove more productive than hours of overtime. That is: don’t overwork yourself, take time off and away.

17 THINK ON PAPER. Write down a problem bothering you, describe why it is disturbing, and list as many solutions as you can think of. This works on life-problems, as well as with individual patient issues that you are trying to complete.

18 BE ABLE TO SWITCH GEARS. Know when it is time to stop and move on to the next important activity.

19 WORK LIKE A PROFESSIONAL, OVERCOME YOUR OWN STUFF. Don’t wait for the right mood. Just start working.

20 BE FLEXIBLE. These are suggestions, not hard-and-fast rules. Experiment, find out what works, and customize ideas to your circumstances and needs. Your patients, your staff, and you, will benefit greatly.