Cost of the Click!

In the article The Hidden Cost of a Click, the author states, “A bad user interface can turn an EMR/EHR into a minefield of medical errors and inefficiency.”

At the present time, the number of clicks necessary to fill out a chart is endlessly time consuming and non-productive.  The cost per click is now being calculated and quantified.  The work flow is slowed down and there is a real-not imagined- price to pay.

One solution is to create an auto-flow sequence that is tunable by site or provider and that comfortably guides the clinician from one area of the chart to another in a logical-customary- sequence.  If an out of sequence entry is desired, this should be easily accomplished.  A system with automatic guidance will eliminate the need to figure out where one should go next, especially if one is interrupted.  When it is acknowledged that one area is complete, it then moves to the next area when documentation is continued or resumed.  Once the area is completed, the list shrinks.  Your favorite click might be auto-sequenced.

An example sequence could be...

• Vital signs
• Triage sheet
•  Past medical history
•  Nursing notes
• History and PE in logical order
• Medical decision making
• CPOE
• Lab and x-ray results
• Clinical course
• Final diagnosis
• Disposition
• e-Prescribing
• Patient education
• Follow-up
• Review nursing notes
• Sign the chart

Navigation would be significantly simplified.  The provider can always go to any area directly and in any order.  Nursing notes might be reviewed, if easily accessible.  Training would be simplified and hopefully stress-reduced.

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.

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.

The Nature of Diagnosis

One of my fundamental thoughts about the diagnostic model in medicine is illustrated by this case from the week's NEJM titled The Deficient Diagnosis.  The authors' comment in the closing paragraph on "circuitous diagnostic route" could (should) be applied to many other clinical situations. That is, most diagnostic routes, except the very obvious are indeed circuitous. And it is this aspect of medical decision refinement that should (or so I think) eliminate the term "errors" from the mix.

Instructive, especially to us, is the child's prior presentation, and the ultimate necessity of coming through the ED to find the true path to a successful diagnostic "route."

Were there errors prior to acquisition of a clinically actionable entity?  I don't see them that way.  Or maybe "hell no!"  This is the nature of medicine, in general.

Compare to someone who arrives with chest pain and acute ST-T elevation. A no-brainer, so to speak. But throw into the mix someone whose EKG and two enzyme sets are  normal, scheduled for a stress-test in 72 hours, and dies of an acute MI in 40 hours. Error? I don't see it that way.  Safe-route?  Not for that patient.

So diagnosis is not static, but dynamic. Even in the NEJM case, once action ability is reached, is that the "final" diagnosis ? (Of course "final diagnosis" is a term we use but applies in most cases to the moment of discharge, highlighting its inherent temporal nature) .   How many times have diagnostic pathways forced our otherwise non-compliant minds into submission to diagnosis' dynamism? Take hypoglycemia --> poor insulin administration --> (wait) Addison's disease --> (wait again) Multiple endocrine adenopathy.  Or chest pain --> acute MI --> aortic dissection.  And on and on.

Diagnosis is not, and should not ever be, a static entity.  What are called "errors" therefore are indeed (expected?) steps off the fastest route.  (That route of course is faster if the patient comes to the ED !!).  I think it would serve the diagnostic error community (if there is one) well, and the emergency medicine community (to which we belong) well if this were better encountered theoretically.  Hence, if done, a path to actionable diagnosis is best served when the time-frame to it is the shortest possible. And the ED is the best site for that !!

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.