Contrary to what you may think, most doctors do want to make eye contact. They aren’t antisocial. They want to engage. But they can’t. They’re too distracted by one of the worst computer games ever invented—the electronic medical record (EMR).
You may be surprised to see the EMR compared to a computer game, but there are many similarities. Both offer a series of clicks with an often-maddening array of tasks to solve. There are templates to follow, boxes to fill in & scoring. However, unlike most electronic games, the points accrued in the EMR often translate into payment—real dollars for either your doctor or the hospital.
Although these clicks and boxes may be necessary to document your visit, it’s distracting. And your doctor begins to feel more like a librarian cataloging information rather than, say, a historian capturing your story.Continue reading…
The rush to implement patient portals to meet Meaningful Use Stage 2 deadlines has focused most attention on getting the technology up and running, and convincing patients and providers to move to shared communication online. Hospitals and health systems have implemented portals with the help of incentives from the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, and patients and providers have been migrating to them at a slow but steady pace.
I am one of the patients eager to see this move to transparency, and have been a user of my health system’s portal from the start. But I’m far from a happy customer and my experience leaves me scratching my head. Sure, I can get online without a problem, and I can read my results.
Recently, I read online that my results were “probably benign (not cancer)” and it would be important to follow up with retesting in six months. This news, delivered with no phone call or follow up from the hospital or my primary care provider, was disconcerting. The specter of cancer was anxiety producing, as it would be for many, especially with no clinical context for interpreting my test results.
I never received human follow up. When finally I reached someone at the hospital to set up an appointment for a retest, I asked about the portal and the message and was referred to the hospital IT Department. Hmmm…I wondered. What does this mean? Is this what patient engagement is all about?Continue reading…
Right now there are two patients in every room. One is made with flesh, bones, and blood. One is made with a monitor, a mouse, and a keyboard.
Both demand my time.
Both demand my concentration.
A little over two weeks ago I wrote the short story Please Choose One. I posted it online. The response it generated exceeded anything I could have ever imagined. It struck a nerve. People contacted me from all over the world, from all walks of life, about the story. Everyone, it seems, can relate to the challenge of having to choose between a person and a screen.
People sent me all kinds of suggestions and ideas. A few sent words of encouragement. Yet, what struck me the most about the people who contacted me was what they did not say. Not a single IT person argued the computer was more important than the patient. Not a single healthcare provider stated they wanted more time with the screen and less time with the patient. And finally, most importantly, not a single patient wrote me and said they wished their doctor or nurse spent more time typing and less time listening.
Medicine is the art of the subtle- the resentful glance from the mother of the newborn presenting with the suspicious bruise, the solitary bead of sweat running down the temple of the fifty three year old truck driver complaining of reflux, the slight flush on the face of the teenage girl when asked if she is having thoughts of hurting herself. These things matter. And these same things are missed when our eyes are on the screen instead of the patient.
As government involvement in U.S. health care deepens—through the Affordable Care Act, Meaningful Use, and the continued revisions and expansions of Medicaid and Medicare—the politically electric watchword is “socialism.”
Online, of course, social media is not a latent communist threat, but rather the most popular destination for internet users around the world.
People, whether out of fear for being left behind, or simply tickled by the ease with which they can publicize their lives, have been sharing every element of their public (and very often, their private) lives with ever-increasing zeal. Pictures, videos, by-the-minute commentary and updates, idle musings, blogs—the means by which people broadcast themselves are as numerous and diverse as sites on the web itself.
Even as the public decries government spying programs and panics at the news of the latest massive data-breach, the daily traffic to sites like Facebook and Twitter—especially through mobile devices—not only stays high, but continues to grow. These sites are designed around users volunteering personal information, from work and education information, to preferences in music, movies, politics, and even romantic partners.
So why not health data?
The story of Chesley “Sully” Sullenberger – the “Miracle on the Hudson” pilot – is a modern American legend. I’ve gotten to know Captain Sullenberger over the past several years, and he is a warm, caring, and thoughtful person who saw, in the aftermath of his feat, an opportunity to promote safety in many industries, including healthcare.
In my continuing series of interviews I conducted for my upcoming book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, here are excerpts of my interview with Sully, conducted at his house in San Francisco’s East Bay, on May 12, 2014.
Bob Wachter: How did people think about automation in the early days of aviation?
Sully Sullenberger: When automation became possible in aviation, people thought, “We can eliminate human error by automating everything.” We’ve learned that automation does not eliminate errors. Rather, it changes the nature of the errors that are made, and it makes possible new kinds of errors. The paradox of cockpit automation is that it can lower the pilot’s workload in phases of flight when the workload is already low, and it can increase the workload when the workload is already high.Continue reading…
Being provocative isn’t always helpful. Such is the case with Fred Trotter’s recent headline ‒ Why Anthem Was Right Not To Encrypt.
His argument that encryption wasn’t to blame for the largest healthcare data breach in U.S. history is technically correct, but lost in that technical argument is the fact that healthcare organizations are notably lax in their overall security profile. I found this out firsthand last year when I logged onto the network of a 300+ bed hospital about 2,000 miles away from my home office in Phoenix. I used a chrome browser and a single malicious IP address that was provided by Norse. I wrote about the details of that here ‒ Just How Secure Are IT Network In Healthcare? Spoiler‒alert, the answer to that question is not very.
I encourage everyone to read Fred’s article, of course, but the gist of his argument is that technically ‒ data encryption isn’t a simple choice and it has the potential to cause data processing delays. That can be a critical decision when the accessibility of patient records are urgently needed. It’s also a valid point to argue that the Anthem breach should not be blamed on data that was unencrypted, but the healine itself is misleading ‒ at best.
”Email is the killer app of patient portals.”
I heard a variation of that quote when interviewing people for the patient-provider communication chapter of the book I co-wrote (HIMSS 2014 Book of the Year –Engage! Transforming Healthcare Through Digital Patient Engagement). For the organizations who’ve pushed patient portals the furthest into their patient base, email has always been the foundation. In other words, email is the gateway drug for patient engagement which Leonard Kish called the blockbuster “drug” of the century.
Physicians are understandably concerned about being overwhelmed by emails if they provide an option for secure messaging. As healthcare transforms, financial incentives have a big effect on the willingness to take on what many perceive to be “more unpaid work” (forgetting the fact that playing voicemail tag is also unpaid and frustratingly inefficient). Interestingly, the physicians who have given out their phone number or enabled secure email (without remuneration) haven’t found they are overwhelmed by any means. In the case of the groundbreaking Open Notes study, many of the doctors just heard crickets.
Please choose one:
The three words blink in front of me on the computer screen.
Please choose one:
I click FEMALE.
I watch as the auto-template feature fills in the paragraph for me based on my choices.
Patient is: 38-year-old female status post motor vehicle accident. Please acknowledge you have reviewed her allergies, medications, and past medical history.
I click YES.
Have you counseled her about smoking cessation?
I click NO.
A little animated icon of a doctor pops up on the screen. His mouth begins to move as if speaking. A speech bubble from a comic strip appears next to it.
“Tip of the day: smoking cessation is important for both the patient’s health and part of a complete billing record.”
The Ebola crisis in Texas has tested our nation’s health care system in many ways, exposing weaknesses and potential breakdowns. In particular, the incident with the first diagnosed Ebola patient at Texas Health Presbyterian underscores a fundamental issue with information liquidity between providers, their care teams, and across the continuum of care. The ability to share information effectively is critical not just in responding to health care crises like Ebola — but also in delivering great, cost-effective care.
As athenahealth CEO Jonathan Bush said in an interview with CNBC earlier this month:
“The worst supply chain in our society is the health information supply chain. It’s just a wonderfully poignant example, [a] reminder of how disconnected our health care system is. … The hyperbole should not be directed at Epic or those guys at Health Texas. The hyperbole has to be directed at the fact that health care is islands of information trying to separately manage a massively complex network.”
The Dallas hospital at the center of the Texas Ebola outbreak has changed its story.
Last Thursday, the hospital blamed a poorly designed electronic medical record for the failure to diagnose Duncan when he arrived at the hospital’s emergency room with symptoms consistent with Ebola, including a fever, stomach cramps and headache. According to the initial story, a badly designed electronic health record workflow made it difficult for doctors to see details of Duncan’s West African travel. Duncan was sent home. Very bad things happened as a result, as we all know by now.
On Friday, the hospital reversed itself without explanation.
The new statement:
Clarification: We would like to clarify a point made in the statement released earlier in the week. As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event. [ Full text ]
In other words: The EMR didn’t do it.
When the EMR story came out Thursday, critics jumped all over it. It did sort of make sense to some people, especially people who aren’t fans of electronic medical records. The idea that a piece of key information could get lost in the maze of screens and pop ups and clicks in a complex medical record sounded plausible.
A lot of other people weren’t buying it:
The swiftness of the hasty retreat led some critics to speculate that Texas Health’s statement Thursday provoked the wrath of EPIC, the hospital’s EMR vendor. Industry critics pointed out that many major EMR vendors, EPIC among them, often include strongly worded clauses in contracts that forbids customers from talking publicly about their products.
After this story was posted, EPIC contacted THCB with a response via email. Company spokesman Shawn Kieseau wrote:
We have no gag clauses in our contracts. We had no legal input or participation in our root cause analysis discussions with Texas Health staff on this issue. Texas Health’s correction is appropriate given the facts in this situation.