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.

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.

The True Cost of Litigation

The battle over malpractice rages on with providers on one side and the lawyers and plaintiffs on the other. The latter side feels that malpractice costs are minimal and simply represent a “cost of doing business,” while providers make the case that they endure unnecessary stress, expenses, and the impossible burden of having to be perfect, 100% of the time. More than unnecessary, providers feel, the tort system for medicine takes them away from direct care activities, and distances them psychologically from their patients.

The article 2% of Physicians Involved in Half of Malpractice Settlements but Few Doctors are Sanctioned makes the claim that malpractice is a function of “bad and incompetent providers”.

“Fewer than 2% of all physicians reporting to National Practitioner Data Bank (NPDB) over the past 25 years were responsible for half of all settlements, a total of more than $41 billion”. The implication being made is that bad doctor’s account for a majority of payouts. That’s just irresponsible hocus-pocus. Why? For for many reasons, but the first glaring one is the other half of settlements therefore come from the remaining 98% of physicians. That’s is a big piece of the medical workforce.  In addition, an obvious bit of statistical legerdemain is present. It is called sampling error.  By just looking at settlements, one only sees the tip of the iceberg.  That’s what sank the Titanic, and it has a sinking effect on the practice of medicine, too.  What is under the surface of such a view? The cost of litigation, defense, trial, deposition, and on-and-on add up to a much more massive number than $41 billion.  And, it does not end there. The costs of psychological stress, work lost, defensive medicine, cumulatively add to the huge burden malpractice litigation places on those whose are just trying to help others by means of medical science.

While the report Medscape Malpractice Report 2015: Why Most Doctors Get Sued states that “Fifty-nine percent of respondents to the Medscape survey have been named in at least one malpractice suit. Nearly half (47%) were among others named in the suit, and 12% were the only parties sued. While among the specialties surveyed, some were sued more than others, no physicians are immune. A 2010 American Medical Association (AMA) survey reported that among all physicians, 61% had been sued by late career

The last article discusses Ten Notable Physician-related Malpractice Statistics, “Most physicians will face a malpractice lawsuit at some point in their careers. More than 61 percent of doctors older than 55 have been sued at least once, according to the AMA.”   “General surgery and OB/GYN physicians are most likely to be sued.  Nearly 70 percent of physicians surveyed in these specialties had been sued, and 50 percent of physicians in these specialties had been sued twice, according to the AMA report.”

It is a fantasy to think that that eliminating “bad” providers will eliminate malpractice. No provider is immune. In fact, almost every physician in a high risk specialty (such as 1.Ob-gyn, 2. General Surgery, 3. Neurosurgery, 4. Orthopedic Surgery, 5. Emergency Medicine) will be named in a lawsuit during their career.

It is important to remember that most statistics do not include the cases where multiple providers are named and subsequently dropped by the plaintiffs. That’s common, as plaintiff’s lawyers generally name everyone whose name appears anywhere they look. Yet, being named alone is more expensive, stressful, and potentially practice changing.

The depth of despair that such suits cause in providers is rarely revealed. Many consider it not unlike a “death in the family,” leading to depression, increased “defensive” medicine, and even leaving the profession. Defensive medicine occurs when patients begin to be seen as potential adversaries, and possible heartaches, instead of someone that needs help. Defensive medicine leads to excessive work-ups and tremendous costs. When the legal profession says that malpractice costs are reasonable, they do not factor in the billions of tests ordered just to cover all bases.

The “other side” is correct that recurrent offenders are infrequently sanctioned. Patients who were injured by “true” incompetence should be compensated, but bad outcomes are not necessarily the results of negligence. Sometimes, though it is not often brought out in litigation, the patient just had a bad disease.

When adding up the potential benefits of removing the malpractice hammer hanging over everybody’s head, the amount would be staggering. Critics would argue that states like Texas have made providers immune to most malpractice, but it takes years to end the paranoia of lawsuits.

Adopting a non-adversarial and non-lottery type malpractice system, across the board, would serve both patients and providers and cut the cost of medicine significantly. But when talking about this huge expense within medicine, it is quite like the elephant in the room that no one wants to admit is there (especially the lawyers).  But the smell is still obvious to everyone.

Saving for a Rainy Day

Saving money for retirement, legacy, charitable giving, and lifestyle can be extremely difficult for most people. My peer group suffers the “Disease of Fixed Expenses”. This is where all the bills and obligations need a certain # of dollars every month to break even. Avoiding this trap with family, relatives, and other financially demanding types at your heels is not simple.

The article Six habits of successful investors gives basic common sense advice that is universal.

1.	Develop a long-term plan—and stick with it.
2.	Be a supersaver.
3.	Stick with stocks, despite volatility.
4.	Be diversified.
5.	Buy low-fee investment products that offer good value
6.	Focus on generating after-tax returns.

   

Creating a savings plan that everyone (your entourage) agrees to is the first step.  Fully fund your Roth IRA's, 401Ks, other pension obligations before you spend any dollars.  Prepare you budget with the money left over from the savings plan, not the opposite directions or there will never be any.

Your savings on average will double every 6-8 years depending on the prevailing interest rates and net returns on your investments. If one could save $100,000 by age 35, one would have $1,600,000 at age 67 by leaving the money alone.       

The greatest misconception that many have in our shoes derives from an absence of financial education. Most of us had none. There is the simple fact that most, therefore, do not get, and if at all, not until too later in life:  money saved, can actually work for you. Yes, that is it. That is correct. Money in the bank can do the equivalent of shifts for you.  In 2016, one million dollars can reasonably bring you in $5000 a month; two million dollars can bring $10,000 and so on.  And when you are in your 60s and 70s (yes you might actually live that long), not having to work those shifts is a blessing.  Think about it: stored work.

The biggest mistakes that my colleagues and I have made concerning retirement are.

1.    Conspicuous consumption

2.    Divorce

3.    Unnecessarily expensive cars (try a Saburu-80-90% of a luxury car)

4.    House poor

5.    Thinking that your home equity is your retirement money. You still have to live somewhere.

6.    Forgetting you will probably live more that 18-20 years past retirement without a check.

7.     Setting limits on your entourage. 5 cell phones and 4 cars can add up.

8.    Severe illness can wipe you out.

9.    Costco $10-15 wine tastes almost as good the $50 wine after the first glass.

10.   Not staying in good physical shape

11.   Etc.

12.   Etc.

In conclusion, save while you are young.

In the ED community there is a new marketing tool—30 minute or less no-wait ED service.

The implication is a provider (physician, PA, or NP) will greet you- a la the Wal-Mart greeter- to begin the service relationship. There are billboards, internet advertising, etc. that proclaim your care will be improved because it will be faster.

If properly conducted where the patient is fully evaluated, there should be significant PRC or Press-Ganey score improvements.

I would prefer to see the metrics based on speed, quality, and outcome.

This would be the “ED Value Plan” that encompasses speed, efficiency, communication, and quality. (9 out of 10 members in my family would choose this plan).

The provider will discharge, admit, or carefully discuss with the patient and family the “Battle Plan” for disposition at the 2 hour mark.
1. Discharge prior than 2 hours
2. Admit prior than 2 hours
3. Discussion with patient.
         a. Outline the timeframe
         b. Discuss need for more tests (CT abdomen)
         c. Waiting for consultant
         d. Providing more treatment to avoid admission (i.e. fluids, 2nd set of troponin levels

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.

Danger of "Burnout"

According to the Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout greater than 40% or 2 in 5 physicians are suffering from “Burnout”. The article in graphic form is worth analyzing.

The data in the article presented below should be read and appreciated.

The main data points are:

1. Emergency physicians are at the highest risk (59%)
2. Interestingly, Psychiatry and mental health practitioners were less at risk, but still above 40%. 
3. Major causes were:

• Bureaucracy
• Too many hours
• Alienation
• Computer/Electronic Medical Record Issues (affect 1 - 3)
• Reimbursement issues
• Specter of malpractice

The data can be understood using the legal term res ipsa loquitur Latin for "the thing speaks for itself".  In other words, it does not take deep analytics to see that the practice of medicine is not as fulfilling as it was in the old days.

`What can be done? A common denominator that links all this dissatisfaction is the endless and laborious need to document using computer platforms that are not developed by those who do not understand the issues facing clinicians. Most enterprise systems are heavily weighted to maximize billing effectiveness. The clinical side of these large systems sits on that foundation. Clinical needs are thus generally ignored, unless, of course, they impact cash flow for the clinic or hospital. A good sports car cannot be built using the infrastructure of a battleship. Fix this chronic overwhelming burden and medical practice will become a combination of science and art that would make clinicians happy, and put the fire-hose to the burnout.