Loss of Common Sense

One of my favorite Meaningful Use Stage 3 requirements is Patient Engagement.  Really???  When does a doctor not have patient engagement?  In the morgue.  This is crazy because it really does not mean PATIENT-DOCTOR interaction...it means PATIENT-EHR interaction.

It is nuts.

Maybe patients should be reading the x-rays; interpreting the labs; discussing findings with consultants.  Who needs doctors anyway?

With the internet, WebMD, Wikipedia, the patient is way smarter than the doctor anyway.  Maybe what we need is a new form of self-care.  The patient can be BOTH patient and doctor  That will really cut costs.  And think of the medical-legal consequences.  The patient has a bad outcome and sues himself.  Whoever is coming up with this stuff needs psychotropic medications.

The Distracted Provider!

The article Is Your Doctor's Distraction a Good Thing tackles a complex problem in the era of the electronic medical record.

A major ongoing complaint is my doctor never listened to anything the patient said.  Add the issue of not making eye contact with the patient because you are staring at a computer screens is leading to chronic discontent in the doctor-patient relationship.

The provider is faced with the task of coordinating endless data streams in a limited time frame.  The provider must obtain the data, synthesize the data, and then incorporate it into a non-friendly computer program.

These are complex multi-tasking events even for the computer literate.  Something has to be lost in these complex transactions.  This is the face-to-face interactions where the patient gets their emotional needs met.  Not all of medical care is pills, but it is psychological reassurance that everything is OK and hopefully will get better.  The important thing for any provider to do is take the time to make eye contact.  Even a short period of eye contact is valuable; and to be effective the indication that is provides, that one is listening, continues through the other non-eye-contact activities.  This is a basic communication necessity that physicians are all too prone to ignore in the midst of thinking about, and sorting out the issues of a patient's problem. 

The article states that the interfaces and programs will improve and hopefully reestablish the human, for the time being, to human interactions that people crave.  I can acquire a Google MD, but it is much more difficult to gain perspective on the various conditions.

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!