Who's Watching Your Back?

It's 2am and you think your condition is deteriorating.  You ring the call bell and hope for the best.  Hopefully, it is not anything serious.

The author of The most important way to stay safe in the hospital- Have a friend or family member with you as much as possible, recommend that you keep your patient advocate by your side.  Hospitals are under immense financial pressure and sometimes the staffing ratios are not in your favor.  The article states that patients with friends and or relatives were treated better, had better interpersonal relationships with the staff, and had better explanations of what was going on.  Almost 30 percent of the patients said they experienced a medical error, such as a wrong diagnosis, medication mishap, or a hospital acquired infection.  They attribute this to a possible nursing shortage.

Even if the hospital is completely staffed, providers must prioritize the needs of multiple patients at the same time.  Your patient advocate can add another set of eyes to your particular necessities.

What is a patient advocate?  These are hospital-based personnel trained to guide you through the maze and interpret often misunderstood medical jargon.  Your family members and friends can help with this process.  The best advice is for them to be around when explanations are being made and hopefully interact with the staff in a positive way on your behalf.

An assertive personality helps, but when human nature is involved use of a carrot rather than a stick will yield better results.  A box of candy or donuts is often the ticket t o a mutually beneficial relationship.  Always have someone there if possible at least:

1. the first 24 hours
2. post-operatively for the first day
3. when crucial decision are being made

When your presence is requested by your family, take the special effort to comply.  You may need that support some day.  The medical environment is sufficiently complex, and the cognitive pressures on patients are not small; hence such support cannot help but be beneficial.

Interoperability via Apps- A guest blog by Dr. Donald Kamens

I came across the article What Doe Epic's App Store Mean for EHR Interoperability?  I had the same conclusion as the author, "This will cement their long-term legacy."

In 2004, then President GW Bush inaugurated the US push toward electronic medical records.  Even at that time, it was recognized that if the effort to have a functional system were to be successful, systems would have to talk with one another, that is, be interoperable.

Fundamental to the concept of interoperability is the principle (or hope) of document exchangeability.  That is, a patient who enters hospital B in city Y should be able to have information from his visit to hospital A in city X sent electronically and incorporated into the care now being delivered.  Interoperability remains a pipe dream.  Why?

There are two fundamental forces at play; one is the complexity of the task such that different parts of the scheme do not inherently understand one another.  The structure of an order set, for example, requires integration to be metabolized and seen within a narrative of care.  Hence narratives are either foregone or synthetic nonsense when left to the cognitive devices of the machine itself.  The other force is the economic benefit that large scale system vendors garner by preventing interoperability with other systems.  MedX can sell more systems if its clients are "stuck" with buying theirs to maintain harmony within the sum of parts.  If a hospital complex as a number of care-settings on campus, and some off-campus, why would they want to risk purchasing an EHR that would not allow conversation between the sites?  Of course, they wouldn't.  And yet, enterprise vendors are rarely able to deliver on the promise of interoperability even between settings that the vendor has supplied, on or off campus.  And that is just the history of a typical single large scale vendor trying to talk to itself.  In one language, in one city, in one country.  You can image the babel when the conversation "should include" machines created by other vendors, at other locations.  It is a mess!  The fall back becomes the fail-safe dependable device for transmitting information: paper.  No one who works in medicine has been immune to the exasperation of creating coherent and reliable, non-fragmented, data accessible, helpful and supportive, medical records.  Pipe dream...

 

In fact, it has been enough of a distant dream, and enough of a perceived necessity, that the US government has incorporated a requirement for interoperability with an "Interoperability Roadmap" within its plans for increased adoption of electronic records and increased abandonment of paper.  Get interoperable, it is saying, or get off the playing field.  This command makes some of the big vendors sweat.

But now there arrives on the scene a large vendor with an idea.  It is a "now why didn't I think of that" type of ah ha moment when one hears the idea.  Epic, perhaps the largest and fastest growing EHR company in the world has said it will solve the interoperability issue by permitting apps t be created, and function within their systems as semi-autonomous modules.  We all know apps, they are on our phones, n our iPads, on our computers.  Short for "application" an app is the ideal platform with to push interoperability.  Apps do not necessarily produce or accept interoperable data, but the vendor that allows an app to function within its technical borders can require that the application is able to function in that respect.  If you live in Rome, the vendor might say, do as the Romans.

Of course, this does not solve the overall nightmare of inter-system interoperability, but it puts it into the hands of module vendors who are historically more capable of solving the issue than the big players.  The larger nightmare will only be awakened from when a cogent interoperability standard, and standard maintenance format, is adopted and required.  Some organizations, for example, HL7 Standards group have been working on this for decades.  There are good schemata that can be applied, therefore, to the issue.

The requirement for standards to achieve interoperability is not a new concept.  Apps to achieve interoperability is entirely new.  Just like the multitude of app vendors one can explore on an Apple or Android device, so the potential for functioning modules within the enterprise EHR systems opens a door that will make clinician choice the center of future EHR purchases.  One considers, the app availability and quality, usually when deciding on an Apple versus Android phone.  Either that, or one is confident the choices will be sufficient to meet needs.

Can't you see yourself reading app reviews to choose the EHR system for your ER or clinic?  Trying out a demo for a few weeks, etc.  It is about to be a new world.  How the economics, security, reliability of this will work, is currently unknown.

One thing is for sure, Epic, not the darling of many clinicians because of its inherently cumbersome interfaces, content building requirement, and progressively ubiquitous presence, has come up with a terrific idea.  Let's see if it comes into play.  If it does, small boutique vendors that have fine-tuned the ways to make ERs and clinics hum, will now be able to offer their products to those who have wanted them.  It will be like putting a fine stereo system in a car.  Hopefully, the music will be good.

Who You Gonna Call???

In the article CA hospital experiences EHR failure, the emergency department closed down after its Electronic Health Record system failed aka went down.  The providers were unable to access old records, verify physician orders, access la and radiology reports, and properly dispense medications.

This hospital either didn't have a back-up plan that was well known to the staff and/or the personnel were unable to create a stop gap solution.

 

The real solution is to have a sophisticated back-up plan that is easily followed and everyone is aware of.  In the old days, paper was used quite successfully to complete all transactions. 

It should be expected that an EHR system will have periods of down-time due to maintenance or the dreaded crash!

Polypharmacy Is Not Just For Getting "High"!

In the article Medication Issues in Urgent Care, Dr. Bhogal points out the complexity of treating elderly patients with multiple medical problems.  More than 40% of senior citizens take more than 5 prescribed medications per month.  20% of Medicare patients have 5 or more chronic conditions and 50% of these take 5+ medications per month.

This subject is so complex elucidating drug-drug interactions, allergic reactions, inappropriate medications, dose-related adverse drug events, and prescribing cascaded- adding a new medication to remedy the side effects f already prescribed medications. 

 

Polypharmacy is a term used to describe a patient who is prescribed four or more medications and generally are adults over the age of 65.  We have often suggested that we no longer list all the medications, but weight them.  Many patient have 3 different version of attain they are taking.  Their medication list does not always include over-the-counter medications, herbals, vitamins, and supplements.

 

The average practitioner cannot keep up with all the medications and interactions without the help of a warning system.  Probably the most common cause of weakness and dizziness after ruling out life-threatening conditions is medication related.

 

The practitioner must have access to the appropriate information.  However, when one looks up any medication, the side effects go on for 3 pages and do not necessarily place the potential problems in any hierarchal order.

 

This is one place where the electronic health record with their CPOE and ePrescribing modules can potentially give real-time information to the providers.  The ability to pull medication history, check drug-drug and drug-allergy interactions for a patient in real-time allows the providers to reconsidered their treatment plan.  Medication reconciliation is a major time consumer, but ultimately needs to be done by the primary care physician or surrogates.  Urgent cares are now providing more and more primary care, so they will need to adapt to this new paradigm.  Everyone always worried about allergies, but drug-drug and drug-allergy interactions, dose-related side effects and cascading prescriptions has added a new complexity. 

 

 



 



Who Owns the Data???

The battle for interoperability and easy data transfer is just beginning.  The author of Electronic Health Record vendors Take Patient Data Hostage: What Should We Do? suggests that the electronic records incentive program aka meaningful use has bee fairly successful in getting providers t adopt and EHR system.  However, the interoperability and goal of instant data sharing has not gained much traction.

The majority of EHR product vendors are unwilling to work with competitors through HL7 interfaces to solve this problem.  They charge exorbitant rates for data transfer and HL7 interfaces.

This leaves the provider with the question, "Who owns the date?".  A cynical view would say that in hierarchical order is the NSA, CMS, Google/Apple, Vendors and lastly the provider and/or patient.  In the article, several solutions are offered such as doing nothing- allow market forces to fix the problem, forcing cooperation through more legislative or administrative mandates, or continue to pay through the meaningful use program for interoperability.

When a provider wants to switch EHR vendors, the issue of data transfer comes up last.  The cost of this process inhibits the practices' desire to try something new and possibly an improvement.  It greatly discourages boutique products that are specifically designed for specific lines of business since the price to interface with balky enterprise systems is cost prohibitive for a small practice.

It will be interesting how the quest for free data belonging to the patient is resolved!

Should There Be a Continuous Medical Education Mandate for Computerized Order Entry and Meaningful Use?

MA Physicians Must Show EHR Proficiency; the State of Massachusetts now has licensure requirements the include proficiency in the user of the Electronic Health Record (EHR).  These include understanding computerized order entry (CPOE), meaningful use, and the core EHR. 

In Florida, there are core continuous medical education (CME) requirements: HIV, medical errors (risk management) and domestic violence.  Clearly, every time a new "hot problem" arises, a new CME requirement is generated.  Next will be Ebola and vaccinations (measles, flu,?).

It is not necessarily bad to make sure that everyone is up to speed on certain topics, but what topics should be selected?  A case can be made for multiple topics both general and specialty specific.

The issue with adding the EHR under the general CME umbrella is a lack of industry standards.  Knowing how to use an EHR at a specific location does not necessarily translate into competence with other EHR applications.  Workflow is characteristically site-specific, so users ma approach the software quite differently.  You would not deal with an automated CPOE interface the same at a 120,000 visit ED as you would at a 14,000 visit ED. CPOE varies from vendor to vendor as well as the workflow for using CPOE from site to site.

 It is often essential to understand the result of a right click on the mouse  on any system. How about when going from system to system?  Will you get rodent dyslexia?  Maybe!?!  For more on the right click, read my prior blog on the Right Click Dilemma!  It is noteworthy that recruitment ads for locum tenens already include the type of system in place at the practice or hospital seeking physicians.

The second piece of the puzzle is understanding meaningful use.  Understanding meaningful use?  Seriously!?!  Remember that MU is the government's attempt to promote adoption of EHRs.  It does not, and should not, directly affect patient care.  Attention to it by practices and hospitals is ordinarily to make sure they get their share of the incentive money.  Physicians are being told, "please check these boxes, so we can be paid", but unless a physician is seeking to become an informatics subspecialist, does he or she really need to know what MU is about?

The ultimate solution is establishing national standards for the operation of any EHR, including CPOE as well as patient databases.  If every system used the same fundamental database and CPOE, the provider can figure out the various approaches used by vendors.  Remember, the Massachusetts medical society backed this issue.  HL7 has been working on it for years, and has many tools to enable EHR standardization.  Why not adopt realistic standards?  That would certainly be a meaningful, and useful thing to do.

Have You Lost That Burning Desire?

Professional, occupational or job burnout is short-term exhaustion, lack of enthusiasm/motivation, feeling drained and most times there is negative emotions and cynical behavior that result in reduced professional efficacy within the workplace. 

The article Is Technology to Blame for Physician Burnout analyzes the Medscape Physician Lifestyle Report, which states the electronic health record is a factor in physician burnout.  The data identifies three key factors: insufficient income due to reimbursement cuts, extended hours to maintain the status quo, and the negative impact of technology (time, money, and more staff).  When is the last time you had someone smile when the acronym EHR is mentioned??

It is no secret that physicians, as well as all other health-care providers, have been endlessly bombarded with massive political, economic, and social change.  Simply for survival, most every physician and provider has had to rethink priorities just to keep afloat. 

The EHR was once touted as a solution to the chaos in health-care. Instead of being an answer, it has become an added burden for providers'.  Why?  One thing, lack of standardization has created an additional unknown in a providers' environment.  What problems is this thing going to give  me today?  Even physicians who practice every day in the same location, are face with technological impediments.  Those who work at different sites, often have to readjust to a different interface on the fly.  Such impediments include surprise updates, new facility and regulatory requirements, restructured workflows, unpredictable interfaces, and software that is anything but friendly. Add to all that the failed pledge of interoperability- my system will talk with your system- and it is easy to see why the EHR simply has not lived up to its promise--Not even close!  These studies show that a majority of physicians have felt that the presence of EHR technology decreased face-to-face time and the ability to see patients, while only a minority felt that the quality of their practice was improved.

Burnout is a major potential problem for the health-care system, for patient care as well as for the individual provider that may fall prey.  In this environment, the EHR is a natural scapegoat for the deeply entrenched ills of the system.  With the rapidly aging physician population, once can understand that doctors are expressing a desire to get out of the click race.  Hopefully, the next generation EHR will be better than the current one.  Maybe the psychological and emotional contribution to the specter of burnout will perhaps lessen, if not disappear.