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.

More Lawsuits More Often

The article EHR safety goes to court discusses a hospital system suing an EHR provider over lack of support due to several safety issues. The issue is complicated by the fact that one provider was purchased by another and then the hospital contracted with a third party. Both claim breech of contract and the hospital system states that patients were harmed.

How were they harmed? There were errors in tracking of patient locations, discharge medications, and there was a general inability to properly use the Computerized Order Entry system (CPOE).  These suits demonstrate that factors such as lack of usability, poor interfaces, poor training, and poor support, inevitably lead to errors. Compound that with the prevalent practice of having non-clinical, non-computer savvy, individuals input sensitive and tricky clinical data, and there is an ever-present recipe for disaster. Why can’t clinicians be counted on to input the data themselves?  Because clinicians really don’t have the time or capacity to deal with poorly designed systems that do not function smoothly and intuitively; caring for patients, rather than nursing IT systems, is their main priority.

The article states: “For years, many patient safety advocates have warned that EHR systems carry numerous potential risks due to their poor design and the ease with which data entry errors can lead to medical mistakes. “ The reality is that highly pressured providers have to make multiple clicks, leading to an exponential rise is the potential for error. Rarely are real-time checks and balances built in, so that a person in-putting data has little, if any, verification, that “STAT ORDERS,” for example, were received and/or acted upon.

Anyone who has attended a risk management or critical incident committee meeting in the E HR era is well aware of the many system based medical errors that arise because of the functionality or lack of functionality of the programs and people interacting with them.  Humans !


System-Based Medical Errors” inevitably lead to litigation that pits provider, hospital, and vendor against one another in a complex legal battle. In general, of course, there is no easy resolution as each side can easily point to the weakness of the other parties.


Moreover, lawyers, doctors, and healthcare systems can count on the fact that there will be competing vendors waiting in the wings with baited breath to take over any system wherein complaints are rising.  In this case Epic took over a Cerner client; but in others Cerner has taken over an Epic client.  This juggling occurs across the board. It is almost (but not quite) as bad a politics.  There are promises, promises.  Oh! The promises.  Most often disregarded (or masked) is the fact that experience shows the same complaints regarding the old system will appear in the newly installed system in short order. The political metaphor aside, it is not unlike the story of Sisyphus; the Greek Titan who rolled a huge stone up the mountain, only to find that the stone rolls back down the mountain; Sisyphus again rolls the stone up the mountain; then down it comes; and so on, and so on, and so on. Indeed this circular manner of problem followed by so-called-solution, followed by reemergence of the problem, and again and again is sadly the way of healthcare IT in 2016.  Sad, for sure.

Bottom line is that with the recent publicity that the third leading cause of death is medical error (a claim that most well-respected authorities feel is without solid basis) there will be evermore scrutiny of the different parties involved. The solutions (user-friendly programs, easy interfaces, easy navigation, national based CPOE and interoperability designed databases, etc.) have been elucidated in previous blogs.

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.

Acute on Chronic Electronic Health Records Dissatisfaction

The slideshow 6 Ways IT is Contributing to Healthcare Inefficiencies examines why there is general dissatisfaction with the Electronic Health Record.

1.      Work-flow issues
a.      When a healthcare IT system impedes workflow, it becomes a major hindrance to efficiency and satisfaction. An EHR should naturally and smoothly integrate into the time-honored workflow of a facility, not the other way around. 
b.      Therefore, changing workflow for the convenience of the electronic record, for billing, for data collection, while ignoring the working process of the providers is an obvious misstep.

2.      Training that never ends.
a.      When a product is not user-friendly and needs multiple classes to teach the provider to navigate through the mess, one has a built-in disaster.
b.      In such situations, the interface is not naturally intuitive, and most providers will have to relearn the entire process after a two-week vacation.
c.       One would think that the American Heart Association’s experience with poor retention after CPR classes would have demonstrated that easier is better.
d.      Lots of visual prompts work better than lots of training and re-training. CPR has been changed to “push on the chest”, defibrillate if possible, and call 911.
e.      Success rates improve with simplicity. Providers agree that most EHRs need to simplify or provide real-time guidance through prompts and orderly flow.

3.      Finding the Information   
a.      There is lots of relevant but buried data in the E HR. But it sits underneath layers in very separate silos. These take significant know-how and effort to access.
b.      It has been noted that finding a key nursing note can be so onerous that the provider gets burned out on the process and when writing WNL actually means “WE NEVER LOOKED”.

4.      Alert fatigue is a dangerous issue.
a.      Warnings and alerts especially in Computerized Provider Order Entry (CPOE) modules wear the provider out psychologically.
b.      Not uncommonly, risk adverse programming triggers these bells and whistles.  Workflow takes a serious hit when the alarms are always going off.

5.      Myths: Bigger is Better; more words are better than a few.
a.      Ask any provider to point out relevant information from a 17 page document and find out what otherwise obvious key data points are only recognized after a problem comes to light.
b.      The retrospectoscope is a more functional modifier of workflow when it is viewing just a compact presentation and report.

6.      Call for a National Data Base
a.      The lack of interoperability and lack of poor, difficult to obtain, communication remains a huge problem. One proffered solution is a National-Data-Base that every E HR vendor uses as its’ clinical data repository.
b.      In that way, any provider could see a problem list, test, treatments, hospitalization, and medications in a real-time basis. Key elements from every encounter would automatically flow into the data base. Pharmacies could also list all prescriptions filled with dates, times, refills etc. The provider would know if the patient is actually filling their prescriptions and what other providers are writing for that patient.
c.       Its implementation, at least in theory would enable the EH R vendor to concentrate on workflow, navigation, and simplification. 
d.      A national CPOE that could be locally modified according to clinical settings could massively improve efficiency.
e.      What a benefit it would be for all if there were common interfaces between EHRs . Providers would not have to learn multiple systems.  But, no, vendors tend to be in favor of non-standardized interfaces. 
f.        When is the last time you tried to pay for groceries with a card swipe that worked the same as the one you used at the store down the block. Never happened. Never will.
g.      If cross-system standardization a fundamental goal, a national data base and national CPOE effort might actually work. With agreed upon standards, across the healthcare IT industry, the money that was spent on meaningful could possibly have created some actual clinical value. But no. We need to have it different on the first floor than on the third; different on this street, than on the next; different in this city than in another.  Back to the drawing board.

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.