Clicking Your Way to Burnout

The Mayo Clinic published the article Electronic medical practice environment can lead to physician burnout that “shows the use of electronic health records and computerized physician order entry leads to lower physician satisfaction and higher rates of professional burnout.”

The negative effects of decreased efficiency, massive clerical burden, and provider burnout counterbalance the positive potential for quality medical care using an Electronic Health Record. These negative forces seem obvious to any practicing provider but are generally lost on administrators, insurance companies, vendors, and governmental agencies.

Logical reasoning would indicate, however, that when providers, including nurses, are “happy,” productivity, motivation, and commitment are increased, leading to higher quality and greater safety in health care.

The authors conclude that:  "Burnout has been shown to erode quality of care, increase risk of medical errors, and lead physicians to reduce clinical work hours, suggesting that the net effect of these electronic tools on quality of care for the U.S. health care system is less clear."

What is the solution? Some have been mentioned multiple times in previous blogs. But here is a list of EHR functionalities that have great potential to impact quality of care:

1.    User-friendly, site specific, specialty specific documentation
2.    Easy navigation with intuitive, user-friendly interfaces 99.9% consistent every day, every site.
3.    Changes, should be made gradually, to avoid having to relearn the program every outing
4.    Uniform CPOE (computerized physician order entry) that is the same in every system
5.    Institution of a national database to encourage real-time interoperability
6.    Voice activated technology built-in
7.    Bringing back the “Ward Clerk” – that is, let the doc do doctoring, the nurse nursing.
8.    Decreasing the work burden-eliminate unnecessary machine time, as well as homework
9.    “Alert” controls.  Too many alerts are ineffective, become “white-noise.”
10.    Ability to see what other people are documenting without making lots of clicks
11.     Every click should be counted to help design a better interface, with minimized clicks.
12.    Keep clinical interaction IT separate from bookkeeping and billing IT.
13.    Artificial intelligence that provides an “instant second opinion.”

Hopefully, the future will brighter. Bean-counters should remember that clicks have financial and psychological costs. And the wrong click could cost thousands of beans.

The Medical Errors Debate

A recent article published in the BMJ has caused a furor in the medical community claiming that medical error is the third leading cause of death in the US.  In the article Sensationalization of Medical Errors: Breaking Down the Data In Order to Improve Patient, the author makes a careful analysis of the data used to come to these conclusions. The methodology of the data collection makes the claims of the study grossly overstated, but does deliver an important message to the medical-industrial complex. 

Wikipedia states a medical error is an error that is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.

This is where the complications arise. Medical errors are and can be dangerously detrimental to certain patients but whether this is a cause and effect relationship can be very difficult to prove. Medical errors are contributory factors.

Medical errors run the gamut of poor communication, failure to diagnose in a timely manner (a complicated legal question), improper medications, not accessing the right data at the right time (a failure of interoperability of the modern Electronic Health Records, multiple intellectual and emotional biases of the providers, system errors (most common) and etc.

Whether a medical error directly cause a death, was contributory to what degree, and/or irrelevant would have to be carefully ascertained on a case by case basis. Making generalizations on death certificates where the data is frequently incorrect leads to suspect conclusions. 

The bottom line is that the medical community should take this article as a warning shot that there are significant problems in the system. Crying foul is not a solution. Moreover, the use of the word “cause” with respect to medical error is totally inappropriate.  We well know, too well, that “proximate cause” without significant other “contributory” factors, is necessary in a tort case. It is no different here.  When the disease is the underlying etiology, and the healthcare system does its best, but fails, as it naturally does now and then, what is the underlying cause?

Certainly minimizing what are termed “errors,” but should more properly be termed “imprecisions” or “flaws” is a goal to which all strive.  But as imperfect beings, subject to many flaws, a perfect medical world is not going to happen. Preventable means zero margin for the humanity under which we all labor. All we can do is our best to keep the imperfections minimized.

Fixing the present Electronic Health Record Systems to give accurate, clinically specific data would go a long way in solving some of the problems. Artificial intelligence giving specific warnings would give the provider an immediate second opinion that may help guide the proper course. Finally society has to come with grips that medical art and science is not perfect and never will be.

Where Does TeleHealth Fit In?

The authors of Telehealth Poised to Revolutionize Health-care review the present and potential trends in telemedicine- "Three trends, all linked, are currently shaping telehealth. The first is the transformation of the application of telehealth from increasing access to health care to providing convenience and eventually reducing cost. The second is the expansion of telehealth from addressing acute conditions to also addressing episodic and chronic conditions. The third is the migration of telehealth from hospitals and satellite clinics to the home and mobile devices."

 The article does an excellent job of delineating the present and potential benefit of telemedicine.

These include:
1.    Availability for underserved areas
2.    Reduction in costs
3.    24 hour service
4.    Providing specialty support in real-time
5.    Real-time ICU coverage
6.    Real-time diagnostic imaging
7.    Clinical consultation on time sensitive dilemmas like acute stroke and emergency treatment
8.    Etc.

These services will continue to expand but eventually spread to ongoing chronic care. A good example is Diabetes Treatment. It has become so complicated with multiple new medications that the average provider may not have the ability or time to coordinate the care. 

Another service will be online support groups for various conditions where the endless questions and concerns of patients can be addressed and supported.

The modern generation will want easy access to health care without the delay and time spent directly visiting a Emergency Department, Urgent Care, and or Primary Care.

Some downsides include: 

1.    Over-consumption of care.
2.    Most illnesses or problems are solved with tincture of time.
3.    Not knowing when it is important to go right to the Emergency Department because of the potential seriousness of the condition.
4.    Getting care from numerous sources without coordination
5.    Almost totally giving up on the regular Family Provider who “knows you”.

There are also legal issues (future malpractice issues), credentialing issues, lack of access to high-speed internet, and the reality that the computer cannot perfor  m life-saving measures or surgery.
Where telehealth fits in with the primary care provider, urgent care, Walmart/CVS, Dr. Google (being your own provider) and the ultimate safety net –The Emergency Department –will have to be figured out.  

“Mama Don’t Let Your Babies Grow Up To Be Doctors”

This is Waylon Jennings' and Willie Nelson's 1978 cover of "Mamas, don't let your babies grow up to be cowboys". The song, originally performed by Ed Bruce, was number 1 on the charts for four weeks in the spring of 1978 and was released on the classic duet album "Waylon & Willie".

In the famous song by Willie Nelson and Waylon Jennings, they opine about the hardships of the “cowboy life”. When asked the question of whether you would want your children or relatives to become physicians in the modern era, the answer is always “YES… but….”

Motivations for becoming a physician are multiple with multiple answers. They are generational in scope and multifactorial. These include:

1. Saving the world

2. Helping mankind

3. A means to an end.

4. Avoiding the draft and the Vietnam War

5. Family tradition

6. Economically motivated

7. Opening doors

8. Raising your social statue

9. Good at “School”

10. etc.

The modern day physician is caught in the trap of the “fantasy” of the good old days and ever-changing landscape. The physician is no longer the perceived expert of their domain but a valued cog in the big picture.

Patients still love their personal physician but want input in all aspects of their care. The paternal system of “I’m The Doctor” no longer works.

The physician is also trapped in the electronic world of endless data capture that is rarely relevant to the individual patient in front of them. Click 18 more boxes and you might get paid. 17 boxes and you get a 50% reduction. Did the patient get better? Who knows?

The modern day physician has become a corporate employee with little autonomy unless you are a dinosaur from the past and cling to your “perceived” freedom. Once you accept Medicare and Medicaid payments, you are indirectly/directly an employee of the government.

Getting back to whether you would recommend it as a career. I would do it over again because of the positives definitely outweigh the negative. Every 10-15 years medicine has been shaken up for financial reasons and everyone survived. The burdens are different but with the proper understanding that early acceptors of change are always the winners.

For Every New Medication 2 Need To Be Removed

One of Donald Trump’s campaign promises was: “I will formulate a rule which says that for every one new regulation, two old regulations must be eliminated.” No matter what you personally feel about the new president this idea makes a lot of sense.  Many would be happy with just “no new rules, period!” But the 2 for 1 rule (a twofer) can easily be transmitted to multiple other areas of consideration, especially in pharmaceutical realm regarding prescribing of endless medications without making the critical decision to eliminate any.

Problems with side effects and medication reactions plague the elderly and/or chronically ill patient who carry or store suitcase full bins of pharmaceuticals. Compounding this, when more than one doctor is involved, they rarely decide in concert what to use, and multiple treatments from a stack of practitioners often lead to serious consequences.

The article Adverse drug reactions in the elderly author quotes, “Medications probably are the single most important health care technology in preventing illness, disability, and death in the geriatric population. Age-related changes in drug disposition and pharmacodynamics responses have significant clinical implications; increased use of a number of medications raises the risk that medicine-related problems may occur. “

The number of patients suffering from polypharmacy, significant adverse reactions, and admissions to the hospital is significant and radically increases with age. Many are dose related which alter blood levels of potentially beneficial medication; these can then become life threatening. A good example is blood thinners whose pharmacology can be affected by multiple contemporaneous common medications like antibiotics or ulcer medications.

In a prior blog, a semi-tongue-in-cheek approach was suggested: if the medication bag was too complicated to list easily then the bag should be weighed, discarded and start new treatment plans from scratch. It is not a bad idea. Why weight it though? Some kind of list should be made before tossing that considers what symptom or problem the pharmaceutical is supposed to address. Then after tossing the bag, one can see if each problem still exists, and if a therapeutic avenue has been taken with the new medications.

In conclusion: many seriously ill patients need multiple medications to survive but after too many, a situation of diminishing returns sets in, and side effects often become more serious than the original problem. Maybe, after 5-6 medications are prescribed for chronic complaints, a serious analysis of the need for “all” of these treatments needs to be done. Taking unnecessary medications can be dangerous, create new clinical problems, and dramatically increase the expense of care. Adopting a policy similar to the regulation policy suggested in the beginning may be a good start.  In fact, any individual on more than 5 medications deserves a review on a regular basis, with the intent of eliminating any that are either ineffective, dangerous, or in excess.

"Take Me to the Emergency Room"

A 2014 18-month study followed 25,000 low-income Oregonians who won Medicaid coverage in a lottery as part of the Oregon Health Insurance Experiment found that expanding health coverage increases emergency room use. If the finding holds true, it could undercut an argument for the new health care reform law.  The claim is that it was seen across all types of visits that could theoretically be handled in a “less-expensive” outpatient setting.

One of the tenets of the Affordable Care Act is that by providing insurance to everyone; this would be lead to limited Emergency Department utilization. The problem is very complex and the government solutions do not reflect the behavior patterns of the healthcare consumer.

A respected Emergency Department and Urgent Care billing  consulting company felt that Emergency Department Visits would increase by 10-20 % and that the self-pay rate would increase from 18-20% to 30%. This is a reflection of increased Medicaid access and patients having to deal with $5-10,000 deductibles. These deductibles turn an insured patient into a de facto self-pay.

The consumers have voted with their feet in the last 15 years and realized the Emergency Departments and Urgent Cares provide excellent care. They also realize that Emergency Departments cannot ask for “cash up front”. An alternative view to over usage of the ED is that the ED has for years been a significant factor in increased excellent health care and coverage. The government may rethink the whole ED dogma and make it a central clearing house that distributes to Urgent Cares, Family Practice, Internal Medicine and various specialties. With a revamping of the payment schedules, this could accommodate consumers and control costs.

Excellent Synopsis of the History of the Electronic Health Record

The HITECH Era in Retrospect by John D. Halamka, M.D., and Micky Tripathi, Ph.D. is an accurate description of the introduction of computerized technology into the medical arena. It is must read for all providers.

Wikipedia states “John D. Halamka is a physician who focuses on the adoption of electronic health records and the secure sharing of healthcare data for care coordination, population health, and quality improvement.” His C.V. emphasizes his credibility.

The multiple blogs co-authored by myself and Dr. Kamens reflect multiple story lines brought up by Dr. Halamka as the benefits and deficits of the Electronic Health Record.

As Dr. Halamka points out, a big factor in the evolution of a tool that should help, but instead harms (thus not in the manner of primum non-nocera) has been government intervention into a process they little understand.  Given oversight throughout the evolution of EHR requirements have been office people, desk sitters, academicians, and others who have little or no actual clinical experience.

As a result, the guidelines through upon which developers have created the software that runs EHRs have been disconnected from real clinical needs and utility. Despite all the negativity, there is hope the electronic interface can be adjusted to the needs of the provider and not just to endless data collection. That however, as noted in the article, will require a commitment to involving providers in creating practical ways to do things better.

“Yada Yada”

"The Yada Yada" is the 153rd episode of the American NBC sitcom Seinfeld. The 19th
episode of the eighth season, it aired on April 24, 1997. “Yada Yada” is boring or empty talk
listening to a lot of yada yada about the economy —often used interjectionally especially in
recounting words regarded as too dull or predictable to be worth repeating.

After writing more than 200 blogs over the last 5 years Electronic Health Records and
Information Technology, myself and my co-author Dr Kamens constantly review the literature
and the same blogs can be printed today that were written 5 years.

There has been quite a bit of progress but no earth-shaking change to improve the
“Electronic Experience”.

Multiple topics have been discussed multiple times:

1. Interoperability-Yada Yada
2. Burden of work on provider-Yada Yada
3. Burnout of provider-Yada Yada
4. Endless clicking-Yada Yada
5. Endless data collection-Yada Yada
6. Destroying the provider-patient relationship-Yada Yada
7. Homework-Yada Yada
8. Etc.-etc.-Yada Yada
9. User-friendly interfaces-Yada Yada
10. Fill in the blank______-Yada Yada

Jerry and George said it best. Yada Yada

Despite the recurrent, endless problems with the Electronic Health Record and it’s desire
to control human behavior (unlikely), we will continue to occasionally inform, amuse or
relate to human user.

Failure to Diagnose

In the wrongful death settlement with DuPage Medical Group, Alexian Brothers and Ochoa family,(Personal Injury Lawyers at Cogan & Power . . .) the plaintiff attorneys recovered more than $3 million dollars in “Failure to Diagnose Case” of a patient who died of a complicated headache. The article states that the patient of their clinic with chronic headaches was seen multiple times with no tests being performed.

This showcases a familiar response to a patient returning for the same complaint multiple times. The providers were suffering from “anchor bias” – relying on the first piece of information offered when making subsequent judgments.

These errors could be avoided by using a risk-factor driven electronic health record to review old records and reminded when important risk factors are ignored.  In the case, it was not differentiating between a benign headache and a life-threatening one by not asking the right questions.

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 claim more than just an association. 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.

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.  But 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?

The Electronic Health Record 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).

“Uberizing” Pre-Hospital Care

An Economic Toolkit for Identifying the Cost of Emergency Medical Services (EMS) Systems: Detailed Methodology of the EMS Cost Analysis Project (EMSCAP)

Medical costs keep rising and are under a great deal of government, societal, and insurance company scrutiny. Rarely discussed in the medical cost debate the true cost versus effectiveness of pre-hospital care.

The entire fire-rescue paradigm has broad support from most constituents but there probably could be some evidence-based cuts. The article above gives some guidelines how this can be attempted.

An interesting phenomenon occurs every time a rescue is dispatched: a fire crew is simultaneously sent out to act as first responders. The rationale four quick response is to arrive within 4 minutes, start CPR, and defibrillate someone with reversible V-fib. Yet, the majority of calls do not need CPR, defibrillation, our even treatment; but at the same time, they cannot be simply left where they are, and therefore need transportation to a care facility. 

Such transports are not only extremely expensive, but also take valuable paramedics out of service to act pretty much as a taxi. Municipalities commonly encounter fire-rescue budget constraints, and many cities now instruct their paramedics to call for a private ambulance themselves when the need is strictly for transport. Of course, such vehicle and personnel shuffling is time-consuming and potentially more expensive.

A potential “out-of-the-box” solution is to take advantage of the Internet, social media, and companies like Uber and Lyft. In the future Uber may be used as the generic name for Internet driven transportation services.

Potential applications are:

1. When a patient needs just transportation, Uber can be called by the fire rescue, paramedics, and or dispatch. A patient may even initiate the call.
2. Cities and Fire Rescues can contract with Uber to send specific taxis with CPR-trained our even ACLS-trained drivers to transport patients who do not need a stretcher for transport.
3. Certain cities are studying paging anybody within 6 blocks of a cardiac arrest victim who has volunteered as a CPR first responder. Specially trained “Uber” drivers that can commence CPR and attach and use the AED can extend this first level of care. Having backup of this type would gou a long way to alleviate community concern, and generally assure that every victim is reached in under 4 minutes

There is considerable potential for cost saving. Think of reductions in fire station construction, personnel, and equipment. All of this could be achieved with little reduction in quality. It’s time to take advantage of social media and include private infrastructure to aid the public good. Perhaps in the future, stories about babies being delivered by taxi-drivers will be replaced by a stories of heroic Uber drivers in that honored role.

Malpractice: A Guide to Getting Sued

This primer on malpractice is an excellent review for all providers regardless of their level of experience. It divides this dark side of practice experience into two realms: protection and defense.

The article is, in reality, a basic “course” that has as its last chapter what should be the first: "How to Avoid Getting Sued", and goes through common sense steps to reduce risk, including being sure you have the right diagnosis, asking for help, retiring when it is time, informing patients of needed tests, being friendly, communicative, and unrushed, following up, and documenting well.  No kidding!

When it comes to what to do, and how to respond when a suit is attempted or initiated, the article notes among other things: “Know how to prepare for depositions and trials to increase your chances of winning” and “Evaluate when to settle vs when to go to trial by weighing key factors.”

Throughout the piece, key factors that lead to malpractice claims are highlighted, including:

• Poor communication
• Not listening
• Not following up labs, tests, and outcomes
• Lack of supervision of team members
• Bad outcomes
• Bad “Luck”
• Being at the wrong place at the wrong time (also known as bad luck)
• System errors- Electronic Health Record issues
• “Lottery Mentality” of some patients (looking to sue they are watching you)
• Being named with multiple other providers (lawyers taking the deep pocket approach that casts a wide net)

Some easy(?) solutions to consider:

• Let the patient talk interrupted for 1-2 minutes before interrupting
• Find out his/her/family’s motivation for the visit
• Find out what the patient/family is concerned about and focus on those issues
• You may have to consciously work to include family members or surrogates
• Apologize for making them wait for you even if they have not
• Control expectations (any test whose results you expect in an hour, should be noted to the patient as requiring three hours)
• Always attempt to involve the patient and family in decision process
• Have a robust follow-up system for all data that is outside of normal range, potentially problematic, or of concern. Also follow up on all patients who were extensively evaluated to be sure they are doing better and to encourage their effort at follow up. Be sure these follow up efforts are well documented.
• Talk in common language without medical jargon (aim at 6th grade level of comprehension)
• Have the patient repeat what the plan is before they leave
• Create focused documentation with pertinent positives and negatives and a cohesive follow-up plan

The bottom line is that when a patient perceives that you are working on his behalf, that you care about him, he (or she) will be reluctant to sue even if inevitably some things go wrong.

What is the Problem with Interoperability?

In a recent article by Dave Levin, MD, the astute and experienced physician points out the "reasonable, but incorrect assumption that two installations of the same EMR can easily share data...The hard truth is that every implementation of an EMR is different and even same-brand EMRs do not seamlessly connect." Why not? It seems almost shameless in an industry that has had a directive to achieve interoperability, at least since George W. Bush's executive order 13335 in April of 2004: "Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator".

That order was made over 13 years ago, the same period in which Facebook became the foremost social network in the world (with extreme interoperability), and about the same time that Amazon expanded into jewelry, shoes, and electronics, rapidly becoming the largest retailer in the world and making its founder, Jeff Bezos, nearly the richest man in the world. Why are EHRs not able to obtain the same level of interoperability?

The missing piece is an absence of standardization. Even within a single vendor, achieving interoperable standards is apparently harder than climbing Everest, and less survivable too. A number of organizations have attempted to create EHR standards, notably HL7. Their valiant efforts have been largely ignored. Again one must ask: why? For the most part, one must point a finger at the government's inability to establish and mandate simple interoperability standards. The efforts that have been made have been an abysmal failure.  Meaningful use? Seriously! Many of us say: meaningless use. It is not a standard, it is a hand-tying imposition on progress. There would be no Facebook, no Amazon, if such impediments were operative in the general internet commerce and social media space.

Think of it this way. GE, Samsung, Amana, Westinghouse, all make refrigerators and other appliances. They all seem to work fine on 120v current. Why? because that is the standard, and the companies know that is how they have to be built. What if (as with EHRs), companies were allowed to construct their innards any which way? We would not have cold food, or ice, dishwashers or air conditioning. None of the devices would be able to talk to the electrical grid. But now, EHR vendors can build what they want, can tell potential client hospitals (as well as the VA and the DOD) that they alone have it together and you better stick with them exclusively. Would we not rather choose an EHR based on how easy it worked? Knowing that it spoke the needed language as a baseline. The culprit in this is VA's and DOD's boss. In 2004, George Bush saw it, but the ability to stand up to the big companies that deliver health care tools is absent.

Until the government gets out of the business of trying to tell doctors how to practice and instead tells vendors they have to make EHRs that meet an interoperable standard, chaos will continue to reign.

Expansion of Nurse Practitioners and Physician Assistants Setting Stage For Single Payer Health Insurance

In the article “Are Nurse Practitioners and PA’s Taking Emergency Physician’s Jobs?,” the author gives an excellent summary of the evolution of the roles of “formally” ancillary providers.

While the dictionary defines ancillary as “subordinate, subsidiary, or assisting,” the article provides statistics on the rapid growth of ancillaries and the expected goal that these second-tier providers will practice in an increasingly autonomous fashion in the future. The majority of ancillaries support “team-based” physician-run practices but do not have decision-making capacity in the practice itself.

With modern technology, advanced training, and prospective financial savings, an ancillary-based model is clearly in the cards for Emergency Departments, urgent care facilities, pharmacy clinics, and other care-delivery locations in the future.  These will likely work with a physician supervisor overseeing a team of ancillary providers (“boots on the ground”). Supervision might occur simply by walking from room to room, over phone lines, or even via video (telemedicine).

With the ever-increasing costs of medical care and difficult access for many, using PA’s and Nurse Practitioners for direct patient contact makes a lot of sense. Will quality suffer? With the availability of direct supervision or advice through communication devices and telemedicine, decrease in quality should be minimal. Studies have shown that the general public is not only supportive of ancillary providers, but appreciate the concern and “bed-side” manner many are able to show, especially compared to negative experiences many have had with more hurried physicians.

In the recent governmental health care debacle over the ACA and “Trump Care”, there is little discussion of cost savings. Media reports show that legislators speak in terms of premium reductions and deductible amounts, and think that having an insurance card equals having medical care. How wrong!

Quite likely, the case for single payer health insurance will be on the table before long. And then, one might see a public safety net system that has premier options for those able to pay out of pocket. NP’s and PA’s will unquestioningly play a significant role in such a more socialized structure.

2-Hour Length of Stay ED, Would You Like Some Fries with That?

In the ED community there is a new marketing tool—30 minute or no-wait Emergency Department.





The implication is that a provider (physician, PA, or NP) will greet you a la WalMart and begin the relationship immediately. There are billboards, internet advertising, etc. that proclaim that your care will be improved because it will be faster.

On the upside, if properly conducted where the patient is fully evaluated there should be significant PRC or Press-Gainey score improvements.

I would prefer to see the metrics based on both speed, quality, and outcome.

Welcome to  the 2 hour LOS ED.

The provider will either discharge, admit, or carefully discuss with the patient and family the “battle plan” for disposition at the 2 hour mark.

1. Discharge prior than 2 hours
2. Admit prior than 2 hours
3. Discussion with patient
   a. Outline the time frame
   b. Discuss need for more tests (i.e. CT abdomen)
   c. Waiting for consultant
   d. Providing more treatment to avoid admission (i.e. fluids, 2nd set of Troponin levels, etc)

This would be the “ED Value Plan” that encompasses speed, efficiency, communication, and quality. (9 out of 10 members in my family would choose this plan).

The Most Expensive Tool in Medicine: "THE CLICK"

In the article "Price transparency in electronic health records not linked to changes in physician ordering: The PRICE trial", a cost analysis was performed on giving feedback to the clinician on their test ordering. The study essentially found “that  electronic health record display of cost for laboratory studies was not linked to a change in clinician ordering habits.” This has been extrapolated to both radiological tests and medications.

In the past the “most expensive tool in medicine” was the pen but this has changed to the “click”. Today, one can order multiple tests, perform them hourly or daily, and prescribe endless medications, all in packages, and with just a click.

The goal and fantasy of the CPOE (Computerized Physician Order Entry) has been that it would lead to cost controls and critical thinking about diagnostic and treatment plans. That imagined goal would be protocol driven, evidence-based, and lead to financially sound actions.

But the devil is in the details. In healthcare IT, that devilish detail is in the implementation of the software design. As it stands, the burden of the various CPOE platforms which include pharmacy, lab, and radiology are so cumbersome that “Work-Arounds” are often taken to get the busy work out of the way. Unfortunately, the devil is winning.

In the past our blogs have suggested a need for an evidence-based national interchangeable CPOE platform that everyone learns and understands. The industrial world knows this by the term “standardization.“  But in the space of technological innovation, standardization is elusive. HL7 has made a valiant effort to standardize the use of electronic medical systems. But standardization has not happened. Why? Think of the credit card readers in supermarkets and stores. Do any work the same as the one down the street? How many times do even non-medical people scratch their heads and make mistakes when simply sliding a card instead of inserting the chip? Not to mention the frustration of the cashier toward the seemingly stupid customer who just cannot get it together.

Medicine should do better. Lives are at stake. Every provider, hospital, and vendor could adjust the content pertaining to the work environment and specialty.

CPOE with enhanced “Artificial Intelligence” could include:

1. Treatment protocols (especially for commonly encountered and high risk clinical presentations)
2. Pharmacy preferences (with one, instead of 18 clicks per Rx)
3. Work-up protocols (that cat an appropriate safety net for some presentations)
4. Financial data
5. Cost effectiveness data    
6. Elimination of boiler-plate, routine, tests
7. Rational for why a certain test is needed unless protocol driven or obvious
8. Feedback to the provider on cost per provider on 1. Diagnosis 2. Treatment compared to all users.
9. Easy or automatic access to up-to-date recommendations for the specific problem.

If all this happened the same way at hospital B as it does at hospital A, think of the overall benefit, efficiency, decreased error, and cost savings that would accrue toward healthcare overall. Familiarity, coupled with true interoperability, would lead to less clicks, less consternation, less mistakes, and even the possibility of more patient contact time.

Currently, practitioners are so overwhelmed with data input that it discernibly takes away from time needed to fully analyze important clinical decisions. As a result, costs go way up. Think though, how the tendency to prioritize getting paid, even if it is perhaps an unconscious tendency, could be replaced by the more important tendency to get “it right.” Costs could go significantly down if there were enough cognitive space to think thoroughly before ordering routine tests that in the end have minimal clinical benefit.

If there were a standardized national performance guide, a decrease in liability issues should naturally occur along with cost savings. Why? Non-essential tests are commonly ordered on the initial evaluation. Sometimes. And when they are not ordered, a malpractice suit can occur because physicians are held to the retrospective analysis of what might have been done when bad-luck cases arise, as they inevitably do.

(See Peter Rosen vs ACEP dispute).

Would it not be nice if the doc could say, “Well, I was just following the standard?”  Case closed. But, on its own, such standardization won’t happen.  Any more than the card readers in Walmart will work identically to the ones at Target.

Yet we in medicine have an obligation to make it happen. As an important first start, fix the CPOE and help providers intuitively and naturally change their behavior for everyone’s good. There are many articles on the cost of clicks in the business literature, sometimes they even work, and sometimes the lessons can even be transferred to medicine.