Malpractice Dangers in the Patient Handoff

In a recent article by Mark Crane, the author makes the statement “The handoff of a patient from one physician to another has long been a weak link in the chain of care that can lead to patient injury and a malpractice suit. Vital information routinely falls through the cracks, and physicians are often confused about who is responsible for follow-up.”

This has been a problem for years and multiple attempts to avoid litigation have had varied results. At least half the focus and any Quality Improvement initiative was built around trying to find a systems solution to avoiding the endless misadventures.

In the old days of paper, blame for problems at this critical juncture of care was often laid on the nuance of paper itself. That is, a major criticism was about the handwriting and layout of the documents used, and it was heard often that one could not read or find things with needed ease and directness. The Electronic Health Record has changed the paradigm. Now it is easy to read, difficult to navigate, and may be less intelligible than scribble, when a computer processor has synthesized sentences.  Meaningful information is hard to find on many electronic platforms. While the key information may be there (somewhere), what you are looking for is often unnecessarily difficult to access and/or act upon. But that is just the documentation piece; there is more danger in handoffs than simply documentation pitfalls.

The study by Crico Strategies found in malpractice cases that “about 30% of the cases include a breakdown in communication, according to its 2015 report.” Because malpractice suits lead to financial losses and psychological pain for those involved, it is worth thinking about how communications fail.

In most Emergency Departments, the entire staff turns over every 9-12 hours. Overlaid on this rotation of personnel are multiple turn-overs of patients that involve not only physicians (ED Physicians and Consultants), but also nursing staff, ancillary staff, support, and clerical staff as well. Our department created a turn-over sheet that asked key details and encouraged a real-time turnover by “rounding on and visiting each patient being handed over”. When patients spoke with their new and old provider together, it put an identifiable face of a caregiver into their minds, and forced elucidation of a timely plan for disposition. The patient and family would get a real-time progress report and that would hopefully help allay their anxieties and frustrations.

When both providers are not physically there, a whole layer of complexity is created with respect to the physician-patient relationships occurring in the ED. The phone is a poor way of turning over patients, but sometimes is necessary when a consultant is on the way and the ED doc is ending a shift. Notes in the Electronic Health Record may or may not be read. The article calls this " Is the concept of signal to noise," he said. "These systems generate a lot of noise, a high volume of data. But what happens when we lose the real signal, the important information we want to convey, amid all the noise?”

There are many pitfalls in the communication process. Sometimes the incoming doc does not really get the clinical picture and diagnostic plan envisioned by the first doc. Following up on abnormal tests is a common pitfall, that has leads to multiple QI programs. Sometimes they work; mostly they do not. When a patient has an abnormal test and does not get the information needed or does not understand the potential importance of real-time action, who or whom is at fault? Well, it is not a person who is a fault. It is the system.  Solving the turnover dilemma requires system modifications, and all those providing care should buy in on it.

The problems are endless but a “Formal Turn-over Process” integrated with appropriate programming in the Electronic Medical Record can help. The trick is make the process essential for success but not overwhelmingly complicated and time consuming. “Clicks” cost time and money, as discussed in prior blogs. Anytime a turn-over event occurs, a good system initiates a safety process that can save the day (and save the patient) in the end. Such safety process should include discharging patients, turning over care to another provider, following up lab and x-ray tests, etc. The paper solution referred to earlier actually worked if used. But we are in a different era, and building in safety nets in key areas, such as with patient turnover, make the promise of an effective EHR closer.

To Err is Not Just Human

In the article How to Eliminate EHR-Based Medical Errors, presents a list of computer errors that affect patient care. While many tend to blame poor programming and software glitches, these developmental issues are only partially to blame. The ultimate culprit is a lack of standardization in EHR systems, in general. Sufficiently standardized systems would make it possible for a physician to enter data at one hospital, and when at a different one, use the very same methods.

 

Unfortunately absence of standardized interfaces is ubiquitous in our currently technological society.  For example, how often does one go to one store, say a grocery store, and when trying to pay for goods, has to deal with a card reading device that is entirely different from the adjacent store.  One has to figure each one out independently. If spending too much time shopping, one could easily run into ten different interfaces.  Quite maddening.  But that is the normal world, one would expect better of medicine and medical technology. Or is that expecting too much?

Some examples of the confusions encountered include:

1.  Data base/CPOE’s (computerized physician order entry systems)have inconsistent dosing for medications, or manages to switch the dosing between 2 medications
a.  Solution is national data base for CPOE. The data base can “live in the cloud” and be accessible to all

2.  Artificial intelligence that is artificial but not intelligent, such as incorrect weight adjustment for natural growth
a.  Solution –data base that is accurately age and weight adjusted and that catches irregularities and sends notification.

3.  Failure to inform clinician of critical lab information is a major problem.  The more clinicians are depending on technology, the more they naturally depend on them to flag problems.
a. Solution –warning system of critical lab results---coordinated through a national data base for national CPOE, mentioned above.

4.  Prescription with wrong decimal point for dangerous medications. Deadly !
a.  Solution—standardized CPOE/Pharmacy and automated safety testing.

5. Duplicate patient records.  How difficult is it when Patient Sam Q. Brown enters and registers as Sam Brown.  But the computer is thrown off by the absent Q…..and then a second record is created, one that does not have all the important information that Sam Q needs to have in place.
a. Database error created by expected variance in human nomenclature. The error should be trapped and the medical team prompted to sort it out and reconcile the records. Google does this, why can’t medicine.

6.  OUTPUT is “Gobblygook” at best. A combination of typing, cut and paste, macros, mini-macros, and  “computerize” that makes no sense. The inputs are all given the instruction to create text. There is no instruction set that can be made which will create automatic meaningful text.
a.  One solution may be greater use of voice recognition. For example, Voice Activated Technology (Dragon) allows a clinician to dictate several common sense sentences about what really happened during the encounter.  Siri does pretty well on this too.  Apple, Dragon do it, why not get medicine more fully on board?

7.  Scanned documents sent to wrong patient.
a.  No fail safe mechanism exists for stupidity or incompetence

8.  Action items never were seen or acted on by the clinician.
a.  Programming issues/inappropriately mild alerts can be blamed, often
b.  Often, it is difficult for a provider to comment on action taken because there is an inability to easily add addendum.  Developers should really try to make the systems at least better than paper in this regard.

The fundament problems are lack of standardization, easy navigation, appropriate warnings, and ______________ fill in the blank. Meaningful use money would have been better spent on a national data base and CPOE. Each vendor could then create their own system with built-in universal knowledge, integration, and interoperability as a baseline.

Deterioration of the House of Medicine

Today's guest blog by Dr. Donald Kamens, discusses the top ten things that have led to the destruction of medical care in the 21st century. Unfortunately, the list is endless. These are in no particular order, except to say, that the next item is often more odious than the previous.  Here, then are some of things that have gone terribly wrong, and from which we seem unable to turn back.

From a doc of four decades, these are some of the forces that have served in the continual and progressive plight of medical care. Here is what I think needs to be eliminated from the House of Medicine: What do you think?

1.            DTC (Direct to consumer) pharma ads.  Think of it.  Can you remember when such a thing was actually a heresy?  Illegal?  If so, you are older (like me!). Then, the sound of a jazz guitar did not conjure up male performance anxiety and a reach for the pill. Then, all the side-effects of any drug were not spouted off by fast-talking actors, and “tell your doctor if…” were not fare for a commercial break.  Most of you know that the doctor-patient relationship is totally undermined by this crass pharma commercialism.  Ads for pharmaceuticals needs to be made illegal again. Let the doctor do the analytics and the deciding. This does not need to be a patient activity, one more closely related to recreational substances than to therapeutic medicines. At least allow the patient to choose whether to have to listen, to hear, that baloney or not. And choose whether to explore through research online or not.  In the meantime, we could let football games be football games, instead of marketing venues for various chemicals. Sure, beer is a chemical, but it is fine.  What to do:  pull the plug on greedy pharmaceutical manipulations that do well to nothing but confuse patients, and distort the role of the doctor.

2.            Barriers to doctor-patient relationship:  The prime examples here are EHR screens, creating ridiculous busy-work that makes seeing patients like filling out tax forms, and increasing pressure to see more patients in less time. Seriously?! Despite being an advocate of EHR from long ago, and an early developer, they have gone to another universe. Now we have complexity after complexity.  The EHR is such a pain, we have an ever increasing presence of scribes and other assistants assigned to deal with the clerical. Does this not attest to the progressive marginalization of the physician from the therapeutic relationship?  What to do:  eliminate documentation criteria; eliminate reimbursement based on completed charting items.  A one line should be good enough.  “Put her on antibiotics for the pneumonia, and told her to see her doctor and/or come back if not better in two-three days, or if worse. “ Not much more needed.

3.            Liability. Little more needs to be said about that nasty word, but just to be clear….here I am, on the way to work; here I am going to go help someone today.  And they often need help it seems. But wait!  I have to worry about being sued. Alost forgot! I have to think about being hurt-back by the one I am trying to help-out. Seriously?  What to do:  tort reform is not a good plan.  Why? The complexity of work-arounds would be just as overwhelming.  Simply do this: eliminate liability.  If you are there to help, you are there to help.  If you screw up, you screw up.  It is going to happen at times. The house of medicine should not allow overwhelming vulnerability, hurt to the one trying to help. Do it Shakespeare’s way, or make suing doctors illegal.  If done, the costs of medicine will go down, down, down.

4.            Reset the goals: Make patient outcome goals vastly more important than economic goals. More important than throughput statistics. Outcomes do not have to be specific (e.g. cure of coronary syndrome)...BUT Can be non-negative intermediate outcome based.  EG—the patient did not die in the ED; or the patient feels better, now, though we do not have a definitive diagnosis.  Other examples of how this has gone awry include readmission criteria -an economic goal gone haywire, causing care to be stopped before its time 2. Inpatient census monitoring - the goal should be zero census, as everyone would then be well   3- etc., etc.)

5.            Role confusion - (no one more confused than patients: who REALLY does what...doctor, nurse, PA, NP, pharmacist, unit secretary............and the ubiquitous "I never got to see the doctor"). Eliminate the vague uniforms.  Make it consistent with consistent name tags. 

6.            Stating Lies, such as health insurance = healthcare.   (Being "insured" in 2016 guarantees neither care, nor an affordable bill) 

7.            Middle men (modern medicine has seen an ascendency of middle men, not only for pharmaceuticals, but also for devices, services, etc. Too many hands in the pie, means the cost goes up, and up).  Why (Why???) do you have to have 100’s of companies trying to get a piece of the ACA or Medicare pie by offering to find YOU the right plan? Why.  Make is simple, stop this stupid spending on overhead.

8.            Fostering of unrealistic expectations - patients, very often, expect to have something available that has actually not yet been invented.  It can be a world of science fiction.  “What do you mean that your hospital cannot get/read the record from that place I was at over vacation??? “  You mean you cannot reverse my husband’s stroke?   On and on.

9.            Blindness: Here we are: what you might see does not really matter; what is recorded does.   Hard evidence (numbers & testing) has displaced observation, history-taking, examination. (Ask any plaintiff's attorney).  

10.        Stabilize the rapidly shifting medical model Pick a recent approach; stay with it as long as possible. Get ready for change.  Why?  (During the time from symptom to diagnosis may be enough time for accepted criteria for a given entity to change).  Too fast to keep up with.

#11 – 1000+ Get the EHR thing right: Look it is ridiculous to have an ever increasing percentage of time spent on wrestling with these things, time that could be used for patient care.  There are not getting better. Even the good companies know it. Government criteria are getting more and more burdensome. The absence of true interoperability is not tolerable, especially to patients who simply cannot understand why hospital X does not have the information from hospital Z. Let alone why doctor A does not have the information from doctor B at the same facility.  It is a mess. Acknowledge it.  No problem was ever solved without admitting it exists.

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.”

It states that 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.

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.

Surviving “Migration” To a New System

Many Practices are faced with the necessity of changing their Electronic Health Records vendor for a variety of reasons. These may include hospital buy-outs, marginal usability and/or poor performance of present EHR, political reasons, interoperability problems, cost, support, expansion, consolidation, and ownership personal preferences.

Commonly, the administrators, clinicians, and technicians involved do not understand the vast complexity and huge potential costs of mid-stream changes trigger. Often, a major issue that arises is the generally encountered requirement that providers maintain records for at least 7 years.      

The Strategies for Switching or Merging EHRs by Shannon Firth makes many reasonable suggestions on how to approach this transition with wisdom. Here are some essentials that the author suggests you think about:

·         Ask: What data do you absolutely have to have in your new system and what's negotiable? One has to decide what data to mine actively and what just to store. You might decide to input data on active patients only, while placing the rest in an accessible database. While you do not want to load up the new system with data you will never use, you also want access to historical data in some cases, should patients reappear (which of course they often tend to do).

·         Consider: Will you choose to load data manually or digitally? Digital loading is extremely expensive. A commonly employed solution is to scan potentially needed old data into a server from which the new system can retrieve. A provider can then access and utilize the previous data. This tends to work for both paper and digital records. You might be safer trying to resist any urge to move all the data all at once. That becomes a mountainous task. Instead, you might be able scan key documents for regular patients when it gets closer to their next appointment. What should you do about problem lists and medications? One approach is to treat patient as if new to the practice, and update the system with a clean slate using the scanned documents as the basis for doing so. This may sound onerous at first, but consider a) problem lists and medication lists frequently become outdated and need a regular “spring cleaning” anyway, 2) you would do this for any new patient anyway and probably correct many erroneous data points in the process.

·         Think About: What data will be archived and how will you find it in a timely way? Have a coherent plan to archive all the data but do not use unless needed. You can then decide what to scan into the new EHR. Medication lists, problem lists, last complete history and physical, and pertinent lab and x-ray data are high on the list, especially for current active patients. Routine follow-up checks can be accessed through the database if necessary.

·         Ponder: Will you maintain your old system? If so, for how long and how much will it cost? What will be the cost to maintain access?  Will you have to pay your old vendor support and updates?.  All this will depend on your changed contract with the previous vendor, and and the price to maintain it on a server, yours (preferably) or theirs. Remember that sever costs are based on amount of data. The author recommended a year.

·         Give thought to: How will new data (laboratory tests, consults etc.) be received? In most cases, this should be done by accepting data into the new EHR automatically using HL7 standard interfaces.

·         Spend time considering: What forms looked like in the old system (especially those for each visit) and how will they look in the new one. This will affect workflow dramatically. Too much change at one time, even if perceived by you as an improvement, is rarely well received. Gradual change is better. Try to pick an EHR that is end-user oriented, with excellent graphic interfaces, and easy navigation. The end-user will reward such efforts with increased satisfaction and potentially increased productivity.

·         Think through: What is the workflow for each type of visit and what forms are used? You might find it best to use a template driven system for quality control and consistency.

A transition of this sort is in no way an easy task, even in the slightest. An important goal, naturally, is to minimize pain and cost. Remember what we have discusses so far does not even begin to examine what many consider to be the more important, and trickier, transitions of practice management and billing.