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A Patient is Not a Shunt

Some people may tell you that health care IT will solve many of the quality and cost problems in health care.

I don’t believe them.

I know a 70-year old man named Carlos (not his real name) who was hospitalized following a bout of hydrocephalus.  Hydrocephalus is a build-up of fluid in the skull, which affects the brain.  Among other things, people with hydrocephalus can be confused, irritable, and nauseous.  Carlos had all of these symptoms.

Carlos’ problem was fixable by inserting a special kind of drain in his head called a “shunt.”  This kind of shunt is, essentially, a series of catheters that runs from the brain into the abdomen, and which drain the excess fluid.  You can’t see it from the outside, so it’s meant to stay inside of you for a very long time.

For a week after Carlos’ shunt was installed, his symptoms completely disappeared.  But they soon started to re-emerge.  Worried, his family took him to the hospital.  Doctors found that his hydrocephalus was back – the shunt wasn’t draining properly.  They admitted him to the hospital, and the next day they put in a new shunt.  The surgery went well.

But again, about a day later, he started to have the same kinds of symptoms.  The doctors sent him for a CT scan, which showed, to their surprise, no problems with the shunt.  Unsure of what to do, they decided to wait and see if the symptoms resolved.  It was possible, they thought, that the symptoms were from the quick drainage of fluid through the shunt.

A doctor friend (call him Lou, although that’s not his name) happened to be visiting while this was going on.  Lou knew that Carlos had been on certain medications for a number of years.

“Has he been getting those medications in the days he’s been in the hospital?”  he asked the attending physician.

“I don’t know,” said the doctor, who went to check the hospital’s electronic medical record system.  “The meds are listed here, but it doesn’t look like he has been getting them.”

It wasn’t entirely shocking, since Carlos had been in and out of surgery.  Still, it was curious.  “What are you getting at?” asked the doctor.

Lou pulled out his iPhone, and looked up the symptoms of withdrawal from the medications Carlos was taking.  He showed them to the attending doctor:  confusion, irritability, nausea.  Very much what they were seeing and trying to explain as having to do with the shunt.

The attending spoke with the other physicians treating Carlos, and decided to put Carlos back on the medications.  His symptoms went away a short time after that.

One doctor I talked to about this story told me the doctors did the right thing.  Carlos had a history of hydrocephalus and problems with his shunt.  It made sense to rule out issues with the shunt before looking for other answers.

But another doctor I spoke with didn’t agree.  Given that the shunt had just been replaced, it seemed premature to try to explain everything by looking for another defective shunt.  Instead, this doctor told me, someone should have taken a look at his history before sending him for another CT scan.  As this doctor put it, “a patient is not a shunt.”

Carlos’ story tells us something about health care information technology that we may not want to hear.

The IT systems in the hospital were mainly used to order the CT scan, and to keep track of…medications that weren’t being given.  The single most important piece of equipment in Carlos’ case was the brain of the doctor treating him. .

Being a good doctor means asking good questions.  Until a computer can do more than come up with good Jeopardy questions, we must realize that we are still reliant on human judgment, and human fallibility.

And we will be for a very long time.

Evan Falchuk is President and Chief Strategy Officer of Best Doctors, Inc. Prior to joining Best Doctors, Inc., in 1999, he was an attorney at the Washington, DC, office of Fried, Frank, Harris, Shriver and Jacobson, where he worked on SEC enforcement cases.

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クロエ バッグChristy N.Satind'ohrx-pharma24hs Recent comment authors
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クロエ バッグ
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だこったのか?のほこりをなだめるためにしくなでるバック、なぜ、いくつかはっている。 Moのクリームはのびは、ビーズのれたのようながオフフックrustledとして、うこ�
クロエ バッグ http://www.esimplifiedinc.com/

Christy N.
Guest

Excellent post. I appreciate it greatly. I don’t usually comment on other peoples post, but I had to thank you for this. Thanks again! Blog On!

rx-pharma24hs
Guest

Nice Stuff…nice Blog.

Evan Falchuk
Guest

It’s a hard topic, because it requires thinking about health care differently than most people are used to doing.
There is a growing body of evidence of the impairment of medical decision-making.
I wrote about one recent study here: http://bit.ly/cpaXiM , but there are many others.
It has something to do with the conditions under which doctors work.
Doctors don’t have the time to think and reflect about their patients. They work in an environment in which spending the kind of time they need is not valued as highly as it should be. Patients suffer needlessly as a result.
Evan

Gary O.
Guest
Gary O.

The author uses fallacious reasoning to reach an absurd conclusion citing one interesting anecdote to support his thesis stated in the first two sentences that it is false that “IT will solve many of the quality and cost problems in health care.” First, he is attempting to convince us that IT should be rejected because mistakes will still be made even after IT is implemented (the “perfect solution fallacy“); he uses a case guaranteed to arouse the emotions (“misleading vividness fallacy“). Of course, the hallmark of these two related fallacies of argument is the omission of any discussion of how… Read more »

Satin
Guest
Satin

Re: “citing one interesting anecdote to support his thesis stated in the first two sentences that it is false that IT will solve many of the quality and cost problems in health care.” Perhaps you’d believe several Wharton professors better? “Information Technology: Not a Cure for the High Cost of Health Care.” http://knowledge.wharton.upenn.edu/article.cfm?articleID=2260 Or perhaps Abraham Verghese, Professor and Senior Associate Chair for the Theory and Practice of Medicine at Stanford, who wrote: … I have similar problems with the way President Obama hopes to pay for the huge and costly health reform package he has in mind that will… Read more »

rbar
Guest
rbar

anon summarized it quite well, but then goes into overstatement overdrive: “HIT should have been a no-brainer in healthcare. This is an information and communication industry! There should already be a figure like Mike Bloomberg, a guy who got rich by bringing IT to the practice of medicine in a user-friendly, mission-critical way. We should be into the 4th or 5th generation of HIT. But the delivery of healthcare is so radically dysfunctional and untethered from the pursuit of quality that HIT has been left completely underdeveloped and ignored. It’s absolutely amazing. It’s like failing to apply statistics or the… Read more »

Robert
Guest
Robert

“Stupid analysis – unfortunately, no. This happened precisely as described.”
Umm . . . does someone want to explain to Evan how an “analysis” differs from an “anecdote”?
I agree with the commenters who have pointed out that “IT versus human judgment” is a false dichotomy. IT in healthcare is about taking smart, caring people and getting the best out of them. If anyone is claiming IT will allow dumb, careless people to practice good medicine, I’d love to know who they are.

Evan Falchuk
Guest

Hi anon, Stupid analysis – unfortunately, no. This happened precisely as described. You may be very surprised that the hospital at which this happened is one of the best in the country – and it’s one of the most embracing of health care IT. It was probably an error to fail to give Carlos the medications. But if the medication had been, for example, Lipitor, we wouldn’t be having this conversation. No, the real problem was the doctors failing to look at Carlos as a whole patient. Good medicine requires judgment and insight, neither of which were on particularly good… Read more »

anon
Guest
anon

Good lord, this is a stupid analysis. HIT makes it easier to deliver good care, much more efficiently. But DUH it does not guarantee it. Facebook makes it easier to stay in touch with friends, but it does not make you popular if basically you are unlikable. DUH. If you’ve got a hospital whose underlying standard of care is so appalling that they fail to maintain a patient’s medications when he is admitted, it’s unsurprising that HIT alone cannot fix the hospital. But as pointed out above, HIT did make it easier for the family to find and correct the… Read more »

Satin
Guest
Satin

Re: : HIT makes it easier to deliver good care, much more efficiently.

Not according to these sources:

http://www.ischool.drexel.edu/faculty/ssilverstein/HITreadinglist.doc

MD as HELL
Guest
MD as HELL

Garbage in, garbage out, Mr. Leith. You go ask to see the bottles of current and past medicines. You call the pharmacy(s) the patient uses.
Do you have the slightest clue how many inaccuracies exist in all medical records? It makes malpractice attorneys lick their chops.
It matters not whether they are electronic or paper. Records are nothing to stake one’s life on.

Evan Falchuk
Guest

imdoc –
I don’t think anyone in Carlos’ case was motivated by the financial rewards of the CT scan, even though it was an avoidable expense.
Many doctors complain – Atul Gawande may be the most famous – of how undervalued doctors’ judgment is, however. This may be part of the explanation of what we saw happen here.
More here: http://bit.ly/1LAOZB
Cheers,
Evan Falchuk

Nancy Sweeny, MD
Guest
Nancy Sweeny, MD

Clearly, this case, and thousands like it,exemplify the failed panacea of HIT, EHR, and CPOE. In this case, the patient was the computer and the shunt. The devices are so cumbersome, error promoting, and cognitively disrupting that the toxicity you report here is widespread. We do not hear about it because of several reasons: 1. Do not disclose contractual agreements 2. Hold harmless clauses 3. The policy of blame the user as the learned intermediary 4. Medical staff “code of conduct” policies that give the hospital administration and its paid HIT champions carte blanche to intimidate and punish any doctor… Read more »

imdoc
Guest
imdoc

To me this story is more about payment dysfunction. ” The single most important piece of equipment in Carlos’ case was the brain of the doctor treating him…”
The financial reward however is to do procedures. I wonder if non-surgeons were consulted to evaluate the confusion.

HITechxpence
Guest
HITechxpence

Margalit is highly conflicted and ought to state exactly what her conflicts are as a promoter and defender of HIT. Was the redo shunt necessary? Was the patient not getting the correct medications prior to the second operation? Was the patient sent home from the hospital on the correct medications the first time? What you describe with excellent clarity is a typical error that paradoxically, is promoted by complex HIT systems. It is why the Health Care Renewal blogger, Dr. Scot Silverstein refers to these devices as errorgenic (error promoting). It is why these devices must undergo safety and efficacy… Read more »

Tom Leith
Guest
Tom Leith

@MD as HELL: It was no different. That is the point Oh c’mon MD. What was it that showed Carlos had been prescribed the meds, and what was it that showed he wasn’t getting them? A paper chart? No. Where would the doc have looked in a paper system? Most likely he wouldn’t have looked — it would have taken too long. He’d go ask a nurse who wouldn’t know any better than he did and she’d spend howsoever long finding the answer, then tracking down the attending to deliver it, who’d turn around and grump some grump at her… Read more »

d'oh
Guest
d'oh

Where would the doc have looked in a paper system?

IN THE NURSE MEDICATION ADMINISTRATION RECORD