It was a mistake to send the Liberian national Thomas Eric Duncan home from a Dallas emergency room after he presented with fever and pain, which were early signs of Ebola infection.
It would be a larger mistake to miss an important learning opportunity. This case demonstrates what I believe to be a major threat to patient safety—caregiver distraction.
Doctors and nurses are increasingly prevented from giving full attention to the important things in patient care. The degree of value-added nonsense has reached the point where delivering basic care has gown dangerous. This morning, in Canada, news of a case of deadly drug interaction occurred because of alert fatigue—or distraction.
I am a cardiologist; I am also a patient. I want the Duncan case to be a turning point, a wake up call, a never event that serves as a spark to improve the delivery of medical care. Right now, all that this case has changed are tweaks to EHR protocols and checklists. We need more than tweaks; we need big changes.
An uncomfortable truth is that medical mistakes are normal. Errors, like this one in Texas, have occurred since doctors started treating patients. The good news is that technology has made medical care better. No credible person suggests a return to the paper-chart era. Yet, it is still our duty to face mistakes, learn from them, and in so doing, improve future care. Being honest about root causes is necessary.
Another truth about medical mistakes is the ensuing rush to inoculate against blame–which always comes. In the Duncan case, initial blame was assigned to the electronic health record. The computer software failed to flag the travel history in the physician “workflow.” (Just using the word, workflow, hints of the bureaucracy problem.) And you know there is trouble when hospital administrators use the passive voice. “Protocols were followed by both the physician and the nurse…”
Continue reading “An Extremely Teachable Moment”
Filed Under: OP-ED, Tech
Tagged: Alert Fatigue, Distracted doctoring, EHR, medical error, Texas Health Presbyterian
Oct 5, 2014
As reported last year at HIMSS and by many online news and opinion sources since, physician dissatisfaction with EHRs is growing. Indeed, while this blog post doesn’t focus on the broader picture, general physician career dissatisfaction is disconcertingly high.
The breakneck push for more and better EHR use as a component of regular medical care is a significant part of that malaise, but it is insufficient as an explanation. For the most part, doctors really don’t like what the health IT industry is giving them to work with. The HIMSS survey proves it, showing that around 40 percent of physicians would not recommend their EHR to a colleague.
One would expect an industry to develop better products and improve usability, acceptance and satisfaction over time. In health IT, the opposite has occurred, with most pointing fingers at Meaningful Use as the culprit for awkward workflows and Rube Goldberg solutions cobbled together so everyone can get paid in a timely manner.
It seems EHRs are taking more time to use rather than less, which was the original goal.
Continue reading “EHR Design: It’s a Matter of Time”
Filed Under: Tech, THCB
Tagged: Ambulatory EMR, Clement McDonald, EHR, Time management, VistA, Workflow management
Sep 22, 2014
CMS recently announced another change to health IT policy in order to offer healthcare providers greater flexibility. But what will the unintended consequences of this latest change be?
Over the Labor Day weekend, CMS announced that the Meaningful Use Stage 2 deadline will be extended through 2016 in order to offer more options and greater flexibility to providers for the certified use of EHRs. In the interest of full disclosure, I found the timing to be strange— a rule published over a holiday weekend seems an odd choice, particularly when it is being touted as a benefit to the industry and the impact on healthcare provider organizations and clinicians, alike, is monumental.
Unfortunately, I think the additional flexibility allotted by this rule is the latest example of the unintended consequences of health IT regulations. In an effort to make things easier and give healthcare providers more leeway, they have, in fact, made the situation unnecessarily more complex.
Agility is not healthcare’s strong suit
It seems at this point, too many options, or waffling between them (for instance the new ICD-10 transition deadline), can be more crippling than stringent regulations, particularly when there is so much on the line. Healthcare organizations don’t have the wherewithal to vacillate with implementations; they are wrestling with string-tight budgets and constantly shifting rules require large cultural and behavioral changes. As a result, as Dr. John Halamka noted, health IT agendas are being constantly hijacked by regulatory changes, such as Meaningful Use and ICD-10.
It now seems that hospital administrative teams and physicians again must endure constantly shifting rules that they’ve been coping with for years under Meaningful Use. As Dr. Ben Kanter, former CMIO of Palomar Health, so astutely noted “A computer system is a tool, just as a scalpel is a tool. What if a surgeon’s scalpel changed every few weeks? How is it possible to deliver good care if the primary tool you are using keeps changing on an irregular basis?” Continue reading “Sometimes the Best Choice is the Simplest One”
Filed Under: THCB
Tagged: Certification, CMS, EHR, ICD-10, Meaningful Use Stage 2, Washington
Sep 5, 2014
Everywhere we turn these days it seems “Big Data” is being touted as a solution for physicians and physician groups who want to participate in Accountable Care Organizations, (ACOs) and/or accountable care-like contracts with payers.
We disagree, and think the accumulated experience about what works and what doesn’t work for care management suggests that a “Small Data” approach might be good enough for many medical groups, while being more immediately implementable and a lot less costly. We’re not convinced, in other words, that the problem for ACOs is a scarcity of data or second rate analytics. Rather, the problem is that we are not taking advantage of, and using more intelligently, the data and analytics already in place, or nearly in place.
For those of you who are interested in the concept of Big Data, Steve Lohr recently wrote a good overview in his column in the New York Times, in which he said:
“Big Data is a shorthand label that typically means applying the tools of artificial intelligence, like machine learning, to vast new troves of data beyond that captured in standard databases. The new data sources include Web-browsing data trails, social network communications, sensor data and surveillance data.”
Applied to health care and ACOs, the proponents of Big Data suggest that some version of IBM’s now-famous Watson, teamed up with arrays of sensors and a very large clinical data repository containing virtually every known fact about all of the patients seen by the medical group, is a needed investment. Of course, many of these data are not currently available in structured, that is computable, format. So one of the costly requirements that Big Data may impose on us results from the need to convert large amounts of unstructured or poorly structured data to structured data. But when that is accomplished, so advocates tell us, Big Data is not only good for quality care, but is “absolutely essential” for attaining the cost efficiency needed by doctors and nurses to have a positive and money-making experience with accountable care shared-savings, gain-share, or risk contracts.
Continue reading “The Power of Small”
Filed Under: Tech
Tagged: Accountable Care Organizations, Big Data, Care management, David C. Kibbe, EHR, Hospitals, PCMH, Physicians, Small Data, Vince Kuraitis
Aug 29, 2014
The new mantra for the medical practice is upgrade, integrate, and outsource according to the results of the Black Book Rankings™ 2014 Survey. Each year, Black Book gathers over 400,000 viewpoints on information technology through an interactive online survey and telephone discussions. The result is an annual barometer of HIT satisfaction and experiences.
This year, three clear trends emerged for practices looking to stay independent in a changing and challenging time in healthcare. While each trend holds its own unique benefits, it is clear from the survey that many practices are looking to implement all three—upgrade technology, implement integrated solutions, and outsource business functions like revenue cycle management.
According to the survey, nearly 90% of physician practices agree their billing and collections systems need upgrading. Over 65% of those practices are considering a combination of new software and outsourcing services. Here are the trends:
Move to Upgrade Outdated Software
Even with recent changes in the CMS EHR Incentive program, delaying the required use of a 2014 Edition CEHRT, many practices do not currently have an EHR that will enable them to attest for meaningful use. In addition, 91% of business managers fear that the ramifications of their outdated and/or auto-piloted revenue cycle management (RCM) systems, particularly those not integrated to EHRs, will force their physician to sell.
As a result of these challenges and other impending changes like ICD-10, 21% of practices are considering an upgrade of their RCM software within the next six to twelve months, and 90% of those are only considering an EHR centric module.
Practices considering upgrades to cloud-based solutions can see other benefits including reduced costs, seamless upgrades, more flexible access, and reduced concerns around storage and security. Continue reading “2014 Black Book Survey Says Majority of Medical Practices Want Updated Software”
Filed Under: THCB
Tagged: 2014 Black Book Survey, EHR, Meaningful Use, RCM
Jun 24, 2014
Health care for veterans has been all over the news. At the same time, the DoD is moving to procure a replacement EHR system. So it seems there is no time like the present to review a recent RAND case studies report entitled “Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value.”
The case studies include a chapter comparing America’s two most broadly deployed EHRs: The VA’s VistA and Epic. The tale RAND tells is not one of different EHR technologies, as both VistA and Epic both employ the MUMPS programming language and file-based database. Rather, it is about how different origins, business models and practices have dramatically influenced the respective systems. As the report itself says, the contrast offers “useful insights into the development, diffusion, and potential future of EHRs.”
VistA, “the archetype of an enterprise-wide EHR solution,” supports the Veterans Health Administration, “the largest integrated delivery system in the United States.” Initial VistA development was a collaborative, distributed, grass-roots effort where individual VA medical centers built out new clinical functionality on a common platform.
In the mid 90’s, VistA became the instrument of change at the VA.
The pace and scope of EHR adoption increased dramatically under the leadership of Dr. Kenneth W. Kizer, who served as the VA’s Undersecretary for Health from 1994 through 1999. Dr. Kizer considered installation of a major system upgrade to be a core element in his effort to transform the organization … Continue reading “How Does the VA’s Technology Rate Against Other EMR Vendors?”
Filed Under: THCB, Uncategorized
Tagged: EHR, Epic, Ken Kizer, MedSphere, Open Source, VA
Jun 10, 2014
EMR Alert – Featuring radiologist note in illegible font color
For the past couple of years I’ve been working as a traveling physician in 13 states across the U.S.
I chose to adopt the “locum tenens lifestyle” because I enjoy the challenge of working with diverse teams of peers and patient populations.
I believe that this kind of work makes me a better doctor, as I am exposed to the widest possible array of technology, specialist experience, and diagnostic (and logistical) conundrums. During my down times I like to think about what I’ve learned so that I can try to make things better for my next group of patients.
This week I’ve been considering how in-patient doctoring has changed since I was in medical school. Unfortunately, my experience is that most of the changes have been for the worse.
While we may have a larger variety of treatment options and better diagnostic capabilities, it seems that we have pursued them at the expense of the fundamentals of good patient care.
What use is a radio-isotope-tagged red blood cell nuclear scan if we forget to stop giving aspirin to someone with a gastrointestinal bleed?
Continue reading “The Medical Chart: Ground Zero for the Deterioration of Patient Care”
Filed Under: Tech, THCB
Tagged: Billing, Clinical Documentation, EHR, Patient Care, personal health records, Physicians, Val Jones
Apr 25, 2014
Did you hear the one about the CMS administrator who was asked what it would take to delay the 2014 ICD-10 implementation deadline? An act of Congress, he smugly replied, according to unverified reports.
Good thing he didn’t say an act of God.
So, now that CMS has been overruled by Congress, who wins and who loses? Who’s happy and who’s not?
The answers to those questions illustrate the resource disparity that prevails in healthcare and, mirroring the broader economy, threatens to get worse. The disappointed Have-a-lot hospitals are equipped with the resources to meet ICD-10 deadlines and always felt pretty confident of a positive outcome; the Have-not facilities were never all that sure they would make it and are breathing a collective sigh of relief.
First off, it is necessary to recognize that ICD-10 is far superior to ICD-9 for expressing clinical diagnoses and procedures. Yes, some of the codes seem ridiculous … “pecked by chickens,” for example. But people do get pecked by chickens, or plowed into by sea lions, so I believe the intent is positive, as will be the results.
An example: I saw my physician this past week at a Have-a-lot health system in San Francisco and I asked what she thinks of the ICD-10 extension.
“We’re already using (ICD-10) in our EHR and it is much better than ICD-9,” she said. “When I want to code for right flank pain, it’s right there. I don’t have to go with back pain or abdominal pain and fudge flank in. It’s easier and more accurate.”
“If I was still on paper and not our EHR, which I like,” she added, “my superbill would go from 1 page to 10. SNOMED works.”
Continue reading “The ICD-10 Extension: For Whatever Reasons, Congress Did the Right Thing.”
Filed Under: Tech, THCB
Tagged: CMS, Edmund Billings, EHR, HIT, Hospitals, ICD-10, ICD-10 Delay, Physicians
Apr 23, 2014
The American Recovery and Reinvestment Act of 2009 (ARRA), sometimes called the Stimulus Act, was an $831 billion economic stimulus package enacted by the 111th Congress in February 2009 and signed into law on February 17, 2009 by the President.
It included $22 billion as incentives to encourage adoption of certified electronic medical records in hospitals and medical practices. The rationale behind the policy directive was clear: system-wide implementation of electronic medical records enables improvement in diagnostics and treatment coordination, fewer errors, and better coordination of patient care by teams of providers.
Almost immediately, the medical community cried foul.
Their primary beef: the cost to implement these new systems would not be recovered by the incentives.
Similarly, physicians pushed back on the conversion of the U.S. coding system from ICD-9 to ICD-10. They did not question the need for the upgrade: the increase from 19,000 to 68,000 codes is necessary to more accurately capture all relevant clinical aspects of a patient’s condition and align our data gathering with 20 other developed systems of the world where ICD-10 is already used.
That health insurers, medical groups, hospitals and others must use the same coding system that reflects advances in how we diagnose and treat seems a no brainer. But some physicians pushed back due to costs and disruption in their practices.
Last week, physicians won a battle: the Centers for Medicaid and Medicare Services (CMS) announced it was delaying the deadline for implementation of ICD-10 for a year, to October 1, 2015.
Continue reading “Health Information Technology: Sorry, There’s No Turning Back!”
Filed Under: OP-ED, Tech, THCB
Tagged: CMS, EHR, HIT, HIT adoption, ICD-10, ICD-10 Delay, Paul Keckley, Physicians, Tech
Apr 20, 2014
At HIMSS 2014, the health information technology’s (HIT) largest annual confab, the bestest-best news we heard from a policy perspective, and maybe even an industry perspective, was the Centers for Medicare & Medicaid Services’ (CMS) dual announcement that there will be no further delays for either Meaningful Use Stage 2 (MU-2) or ICD-10.
Perhaps we should have immediately directed our gaze skyward in search of the second shoe preparing to drop.
As it turns out, CMS de facto back-doored an MU-2 delay by issuing broad “hardship” exemptions from scheduled MU-2 penalties. To wit: any provider whose health IT vendor is unprepared to meet MU-2 deadlines, established lo these many months ago, is eligible for a “hardship” exemption.
Few would disagree with the notion that it’s unproductive to criticize policy without offering constructive ideas to fix the underlying problems.
Here, the underlying problem is easy to define: it is in point of irrefutable fact fundamentally unfair to penalize care providers for their vendors’ failings—especially when the very government proposing to penalize them put its seal of approval on the vendors’ foreheads to begin with.
CMS’s move to exempt providers from those penalties is correctly motivated, but it seeks to ease the provider pain without addressing its cause.
Instead of issuing a blanket exemption for use of unprepared vendors, CMS should:
- Waive penalties only for those providers who take steps to replace their inferior technologies with systems that can meet the demands of the 21st century’s information economy;
- Publish lists of health IT vendors whose systems are the basis for a hardship exemption, along with an accounting of how many of those 21 billion dollars have been paid to subsidize those vendors’ products; and
- Immediately initiate a reevaluation of the MU certification of any vendor whose products form the basis for a hardship exemption.
This proposal might seem bold, but if we’re truly looking to advance health care through the application and use of EHR, then what I’ve outlined above simply represents necessary and sound public policy. Current practice rewards vendors whose products are falling short by perpetuating subsidies for those products.
The federal government should stop paying doctors to implement health IT that cannot meet the standards of the program under which the payments are issued. That’s just a no-brainer.
An EHR should not be a federally-subsidized “hardship.”
Continue reading “Congratulations, Doctor, On Your Federally-Subsidized “Hardship””
Filed Under: Tech, THCB
Tagged: CMS, Dan Haley, EHR, EHR vendors, Hardship Exemption, HIMSS 2014, HIT, Meaningful Use Stage 2, Providers
Mar 13, 2014