President Obama Delivers Eulogy at Charleston Shooting Funeral of Clementa Pinckney
President Obama Delivers Eulogy at Charleston Shooting Funeral of Clementa Pinckney
Well, it seems that I’ve been on a bit of a rant lately regarding Electronic Medical Records. The subtitle of this blog, however, says “Life, Writing, and Surgery”: or something like that. So I feel compelled to move on, at least for the moment, to something other than Surgery.
It has been a very long time since I posted on the subject of Writing, so I don’t think it is too much of an imposition to provide the following post. What follows is Chapter One from the second book in The Claddagh Trilogy, entitled The Problem With God. It is, in my opinion, the best bit that I have written in this series to date, featuring the best dog character in a novel since Toto (my opinion again). Feel free to try it, with the idea being that if you don’t like this, chances are pretty darn good that you won’t enjoy the rest of my novels.
Excerpt from The Problem with God:
Father Julius Zimmerman was in Hell. Hell, it turned out, looked and smelled an awful lot like Helmand Province in Afghanistan. He wasn’t surprised. He was dripping in sweat. Of course he was, it was hot as Hell in here. He sat in an armored personnel carrier with his squad. It was stifling, as usual. He turned to smile at his squad mates, noticing that they were all dressed in the same cowled woolen robes he had worn as a novice. As his buddy next to him turned to smile back, Zimmerman saw that the other man’s face was a skull, smiling. Julius started to scream.
The explosion lifted the APC straight into the air. It crashed back to earth with a grinding shriek. The air in the small vehicle became a stifling, putrid miasma that smelled of death. Julius twisted violently to free himself of the wreckage entangling him. His eyes snapped open and his breath caught in his throat. Jack, his English bulldog, was staring at him, muzzle drooling on the bed and nose a half inch from his own. Dog breath. Julius screamed again, for real this time. Jack almost blinked.
“Shit, Jack,” Julius yelled, “You scared the crap out of me.” Julius fought to disentangle himself from the blankets that had twisted around him as he thrashed through his nightmare. He finally succeeded and swung his feet over the side of the bed, sitting up. He bent to scratch Jack’s head
“Ready to go, huh?” Jack just stared back, unblinking. Julius didn’t think the dog ever blinked. Julius went to get up, putting his hand in the small pond of drool Jack had left on his bed. “Aww, shit, Jack. I just washed these sheets.” Jack just stared back. “Don’t get so upset,” Julius continued. “It’s okay. I’ll take care of it. Don’t be so hard on yourself.” Jack just stared at him. Julius scratched the dog’s head again and went to the bathroom.
Zimmerman came out in his Georgetown hooded sweatshirt and shorts. He grabbed his phone off the charger and dropped it in the waterproof bag with a handful of dog snacks and a bottle of water. “Let’s go, buddy. You got point.” The dog shuffled out as Julius held the door open. Zimmerman followed outside into the predawn darkness, carrying the bag. The early morning chill was refreshing, dew on the grass stretching down to the river. Julius forced himself not to check his six as he followed Jack’s waddling ass down to the boathouse.
Jack just sat watching on the dock as Julius flipped the two-man scull off the rack. “Two-man scull, two men’s skulls,” Julius muttered to himself as he lowered the craft into the water. It was heavy, almost a hundred pounds and ungainly, but Julius expertly flipped it into position next to the dock with a soft splash. He dropped the bag into the back of the boat and held it steady to the dock. “What are you waiting for?” he growled at the dog. Jack twisted his head quizzically for a moment, then padded over and dropped like a bowling ball into the boat. The dog took a seat behind the bag, facing front. Julius slipped into the front seat, facing backwards towards Jack, stretching arms and legs as he slid the seat back and forth on its silent mechanism. Julius had just greased the tracks and oarlocks yesterday. He liked quiet.
“Clear to the rear,” Zimmerman announced quietly. “Clear to the front?” he asked the dog. Jack stared past Zimmerman and said nothing. “Good to go, then.” Zimmerman pushed off from the dock. He fitted his long graphite oars to their locks and began an easy pull upstream to the middle of the Potomac. It was still dark, but a lighter purple over the Gothic towers of the university hinted at the dawn to come. Zimmerman started to pull harder, settling down to his warm-up cadence. He stared back at the dog staring at him. “When are you going learn to row? I’m getting a little tired of hauling your fat ass up and down this river.” Jack tilted his head. “You know what I’m talking about, dog-breath. Getting a little jiggly around the middle. No snacks until we clear the Chain Bridge.” Jack laid down on the ditty bag, settling his muzzle on his paws. He looked sad.
Zimmerman began to slowly increase his cadence, sliding and pulling in concert to the soft splashing of the dipping oars. Despite the cold, a sheen of sweat appeared on his forehead. He concentrated on his breathing. He was an “empty-lung technique” guy, inhaling steadily during the power stroke, emptying his lungs slowly during the recovery, his chest empty and his knees tight in, squeezing every bit of air out at the catch, then the cadence beginning again, his powerful chest filling with air as he pulled with his back and shoulders, pushed with his legs and felt the trembling boat shoot forward through the glassy water. He was a human metronome, a sweating piston pumping within the scull’s smooth cylinder, watching his wake curve smoothly downstream.
Jack’s head came up off his paws. He made a thrumming sound with his throat and looked at Julius. “What?” Zimmerman asked between breaths. “You say something?” A second later they passed under the Chain Bridge. “Oh. You said bridge, huh? Fine, go ahead. Lard-ass.” Jack chose not to reply to this, instead nuzzling into the ditty bag and coming out with a dog treat. “Just one, lard-ass. It’s Wednesday, we’re going for distance today. Better make ‘em last.” Jack made his sad sound and settled into chewing on the snack.
Julius settled into his endurance cadence. He no longer wore a heart monitor or brought along his little electronic metronome. After four years of rowing three times a week, his body knew what to do. He didn’t think. That was the best part. He pulled, the oars splashed, the water slipped by. He felt a trickle of sweat travel the length of his spine. He kept to the middle of the river, somewhat narrower here as he headed north, the yards and yards drifting behind him marked by the little whirlpools left by his curved oar blades. Silence, if you didn’t count the loud snuffling of Jack polishing off his treat. Jack looked into his eyes, head tilted.
“No more. Not until the next bridge.” Jack made his sad sound again, a deeper thrum ending with a higher note that always sounded to Julius like his ex-wife saying “Fuck you.” Pity, that. He breathed, pulled harder but no faster. The water flowed past, the river making its slow turn to the west. Julius could see the dawn threatening to break behind them as he fought to race away. Sweat started to drip down his nose. Pulling, breathing, pulling, breathing. Jack started to snore.
Jack’s head came up and Zimmerman knew he must be nearing the Beltway bridge. How long had he been rowing? He didn’t know, didn’t wear a watch. Pulling, breathing. A drop of sweat rolled into his eye and he tried to blink it away as the huge mass of the bridge passed darkly overhead. Julius could hear the early morning traffic noises as he shot like an arrow out from under the bridge. Sweat in both eyes now and it wouldn’t blink away. He couldn’t see, was blinded by the sweat and the sun rising like a searchlight over the bridge, straight into his eyes.
“Dammit,” he said out loud, shipping his oars and rubbing at his eyes with the heels of both hands. He had been in a trance, moving at speed like a perfectly tuned machine, hadn’t been thinking or feeling or anything and then—stupid sweat, stupid sun, he thought. He looked back at Jack, who was waiting to be told he could get his snack. Something caught his eye, however, something about the bridge. He looked up, squinting into the sun which was intensely bright, exactly behind the bridge. Something on the bride—a person. Standing on the railing, a person, silhouetted by the bright sun behind. A girl, he thought, the light streaming through a loose white dress or something, her figure in dark relief within. He stared, transfixed, his eyes watering from trying to squint into the sun. It was a vision, he thought. An angel, an angel from heaven. He could make out a ring of red fire, a halo, about her head, lit from the sun behind. Everything else about her was in shadow. As Julius watched, she raised her arms, outstretched. Jack barked, once. An angel, he sees it too, Julius thought. Just then, the vision started to shrink. Zimmerman stared, confused, until he realized that she wasn’t shrinking. She was falling, pitching head first over the side of the bridge.
“Holy Shit!” Julius snapped out of his trance and struggled to unship the oars. His boat was whispering away from the bridge, farther and farther as he watched the figure fall silently, slowly. She hit the water with a sickening splash and disappeared. Jack made his sad sound. Waves lapped at the boat.
“Shit, shit, shit,” Julius said as he struggled to bring the scull about. This was exactly what the small boat was designed not to do. He fought the craft, backing one oar and pulling hard with the other, the graphite bending and locks creaking with the strain. It seemed to take forever to bring it around, to start the pull back to the bridge. “Do you see her, Jack? Is she there?” Jack barked, once; now hopping past Julius to the bow, front paws on the gunnel, staring ahead. He barked again, his stub of a tail wagging. Julius kept shooting glances over his shoulder to try to see ahead but could only see Jack’s butt wiggling emphatically side to side. “Get down, Jack. Down, dammit! If you fall in, you’re gonna sink like a rock!” Jack turned to look back at Julius. He made the ‘fuck you’ sound. Then he returned to looking forward.
Julius thought he was getting close, but wasn’t sure until Jack started barking. Jack almost never barked, almost always in the context of pizza. He was barking like a crazy dog now, though. He kept looking back to Julius, then to the water. Julius used the oars to brake the boat to a stop. He got up on his knees and scanned the water. He saw nothing. Jack was hopping up and down with his front paws on the gunnel, barking. Jack never hopped.
“Dammit, Jack! Get down here, you’re gonna fall in.” Julius wished again that the stubborn animal would wear his life jacket once in a while. Jack had always refused, making the sad sound whenever Julius had put it on him. Julius had made him wear it once, despite Jack’s complaining. The next morning he found it chewed to shreds.
Jack was looking just ahead of the boat now, steadily alternating barks with thrumming sounds, not hopping anymore. Julius was trying to think what to do, not even sure he had really seen the girl. But Jack had seen her, too, he was sure. As he stared at the same spot in the river as Jack, her white figure rose to the surface. Silently, her inert form surfaced, face down, her arms outstretched. A formless white dress clung gauzily to her. She didn’t move.
Without a thought, Julius rolled over the gunnel into the river. The boat rolled as he dropped smoothly underwater, knocking Jack off the gunwale. Julius came up, suddenly realizing that his jump must have rolled the boat. He looked from the floating girl to the boat. No Jack! “Oh my god!” Julius stretched for the boat as Jack’s head came up. He had been knocked into the bottom of the boat, but now stood with paws on the gunwale again. He barked and looked at the girl. Julius just shook his head and turned to swim for the girl. Julius was a strong swimmer, most ex-Navy Seals were. He was at the girl in three strokes and rolled her face up, treading water. He brought his arm under hers and around her chest. He could feel her breathing. She’s alive. He turned with her, twisting to see where he was, where was his boat. Where was his boat? He turned and saw his boat, and Jack still standing on the gunwale, looking at him. The boat was moving downstream, moving with increasing speed away from him. Jack stared, twisted his head questioningly.
“Stay, Jack! Stay! Don’t jump! Stay in the boat!” Julius looked at Jack, at the receding boat, back down at the girl in his arms. He looked back to Jack, now moving more swiftly downstream. “I’m sorry, Jack. I’m sorry.” The boat was moving faster.
Julius swam for the riverbank, carefully holding the girl’s head above water. By the time he had pulled her ashore, the boat had disappeared downstream.
End of excerpt from The Problem with God
Now, if you did enjoy that somewhat, don’t buy the book! But you should go ahead and buy the first book in the trilogy, entitled God Bless the Dead. Works out much better that way. Oh, and by the way, all proceeds from sales of GBTD go to charity to support research concerning mental illness. So there’s that, too.
Implementation of the Electronic Medical Record in a hospital or office setting carries inherent risk. Like all medical technology, there is danger as well as benefit to the patient. Unfortunately, this aspect of EMR implementation has been woefully neglected. Our approach has been to consider the EMR no more risky than the doctor’s pen it replaces. This could not be farther from the truth. I refer the interested reader to the following blog post as an introduction to this fact:
Next time, we’ll explore this aspect of EMR implementation further.
It is not difficult to envision a better EMR than already exists on the market, because they all suck. And they all suck for the exact same reason: They were designed by software developers, not health care professionals. They should all carry a label–Caution: This product was never intended for actual use by a doctor or nurse in the care of a live patient. This fact is obvious to anyone who is forced to use one of these programs while sitting in front of a patient, as opposed to running a demo of the product in front of a group of naive physicians. Gee, we all think, it looked like it worked when the guy was clicking through all those “uniquely designed, personally templated, specialty specific and easily customized” screens. Which, in case you still haven’t figured it out, weren’t really running the program but were just carefully choreographed prescripted, preloaded, dummy demo’s. You figured that out after you bought it, right?
Step One and Only in designing a real EMR: Make the EMR fit the health care professional, not the other way around. Doctors do not sit in front of fixed monitors with a mouse and keyboard. They sit in front of patients. We reach out and touch the patients occasionally (well, some of us still do, anyway). We make eye contact with the patient and family members, not with a computer screen while we ask questions of the patient over our shoulder. Doctors and nurses do not click radio buttons. We don’t do “drop-downs.” I decide what fields are mandatory, not some hospital IT guy who gets told by the CFO that the hospital reimbursement will go up if we can make the doctors document the reason the patient is in the hospital on every note, every day, every time he tries to type anything into the medical record. The medical record is to serve the health care professional’s goal to care for the patient. Let’s repeat that: The medical record is to serve the health care professional’s goal to care for the patient. It is not, therefore, to be designed to maximize hospital reimbursement, regulatory compliance foibles, or translate efficiently into some midlevel administrator’s Excel spreadsheet program to make his quarterly report easier to format. Because you are screwing up the patient’s quality of care just so you can make it easier to run a report on how screwed up the quality of care has now become. Are you with me here?
The following has been proven by multiple, reproducible, double-blind, multicenter clinical trials published in the best peer-reviewed journals: There has never been a system more efficient in accurately documenting patient care than a doctor or nurse dictating their findings and plans into a hand held recording device that they carry with them, the results of which get accurately transcribed, reviewed, and signed. This is the way we document our office visits with patients. This is the way we document discharge and transfer notes. This is the way we document our operative care. It is not helpful, accurate, or appropriate to replace this with a single check-off box that describes my operation as “Repair hernia, inguinal.” But now we can do even better than a simple dictaphone and transcriptionist. Every nurse, doctor, and health care professional in practice for more than a month falls into certain documentary habits, certain turns of phrase, that he uses over and over again. These can be templated, triggered by certain verbal or tactile cues, then easily augmented and modified on the fly to suit the individual patient experience. Reviewed, proofed, and corrected in real time, then electronically signed, sealed, and delivered. Poof! The technology exists. It has existed for twenty years. It’s just that nobody cares enough about the way we actually do things to design this form of input into the multimillion dollar boondoggle that is your hospital EMR. They need to implement this form of input. Mouse clicks and managed care don’t mix. Are you a seventy-year old primary care physician who has always handwritten his notes in illuminated manuscript grade calligraphy with a gold-nibbed fountain pen? Fine, use your nib on a handwriting recognition tablet running Evernote. We’re not trying to put a man on Mars, here. This isn’t a technology problem. It’s an attitutude problem. And the EMR providers attitude is “Screw it, Jack, just write the code. They have to buy it because the government says so.” I’m sorry, I digress.
Doctors and nurses don’t sit down much. We can’t wait until we find a convenient open work station to write the orders that will save the patient’s life. “I’m a doctor, Jim, not a damn transcriptionist!” Or something like that. Your hospital ER will never have enough computer workstations to allow you to provide timely care to your patient when the patients are lined up in the hallways on a busy Saturday night. I need to do my doctor thing on my handy, personalized tablet that I carry with me whenever I am playing doctor. It contains all my personal professional documenting tidbits. It has wireless access to the hospital medical records database, the laboratory database, the radiology database with images available for my review when the radiologist reading of my patient’s CT scan sounds a little–oh, I don’t know, a little ‘intoxicated’ perhaps–and access to my office server with all my personal patient records. It turns on and trusts that I am me because it recognizes my fingerprint, so I don’t have to keep coming up with a dozen new passwords every ninety days to keep some IT guy happily HIPAA compliant. It even can play me the basketball game that I’m missing while I wait for the nurses to come in to do my emergency case. I can talk to it, and I can write on it, and I can tap on it–I can do things that make my care of the patient easy,and efficient, and better. And I can decide how I want to do that, not the hospital administrator who got taken to that “conference” in Vegas on EMR implementation just before deciding which vendor to sign with. Do I sound bitter? Sorry.
I can write orders on my personal little tablet and they get sent to the hospital order computer thing. No more verbal orders. No more orders appearing in my electronic inbox screaming to be signed when I’m sure I was no where near drunk enough to order that stuff last night. But hell, got to sign it or it’ll just bounce back anyway. If it isn’t on my personal tablet, I didn’t do it. So there. My customized order sets, entered with a finger swoosh. Because I write the same orders for patients over and over again. I don’t want to have to make my own special sauce at every hospital, ambulatory surgery center, clinic, nursing home, homeless shelter, and my office. Then rewrite my personal note templates and order sets every time the IT guy decides to trip over the mainframe plug or do “mandatory system maintenance.” I’ll just keep that stuff with me, thank you. You figure out how to make it easy for me to jack my pad into your system, or I’ll go to a hospital that will.
All of this new electronic, streamlined patient-centric data input is to be automatically, consistently, and reliably entered into my personal database, not just yours, hospital administrator. I need to keep an accurate record of how many gastric resections I performed in the past 10 years and how many of those patients died within 6 months of surgery. I need to be able to easily upload my data to the various Boards, Colleges, and regulatory agencies that demand I prove that I’m a good doctor on a frequent basis. The data automatically and easily transfers to my billing software, not just yours. I’m the one generating the data, I think I should be benefitting from the effort. Harrumph.
I could go on. I’m sure you have lots of even better ideas. It’s a start, at least.
The almost over half-dozen regular visitors to this blog know that I much prefer “snarky” over “wonky.” However, this is serious stuff (see parts 1 and part 2 of this discussion), and I’m sorry to say that we’ll be eschewing the alliteratively amusing yet enlightening parable on this one for the tediously technical. Non-physicians are encouraged to move on to this entertaining dog video:
Seriously, it’s a great video, where these dogs are dressed up as US Supreme Court Justices. Even if you think you’re going to read this wonkishly tiresome tirade, take a moment first. It’ll make the process more palatable. Or whiskey. That works, too.
As you may have gleaned from Parts 1 and 2, I believe the current state of the EMR mandated implementation to be no less than a public health crisis. Over the top? I don’t think so. Please ask any physician, nurse, or health care practitioner in the country. I’ll wait.
See? We have to take meaningful, immediate actions to save patient lives and stop the documentary disease that is degrading medical record keeping even as we speak. My recommendations, therefore, are simple and immediate. Here they are:
Step 1: CMS is to immediately suspend the “meaningful use” mandate. Financial bonuses for those practitioners who implemented EMR should, of course, remain in place. These folks laid out a lot of good money based on this expectation. But we should immediately lift the threat of financial penalties for those practices that have not yet fallen down this well. This will also come as a great relief to the hundreds of practices that paid tens of thousands of dollars to install an EMR and have, in practice, chucked it into the closet because they found it unworkable, and therefore have not been able to meet meaningful use criteria.
Step 2: Immediately charge the Bureau of Weights and Measures to develop, in a timely fashion, minimum standards for electronic medical record keeping. Believe me, I would never have thought this up on my own–this was the plan back in the day when we were all talking about how great it would be to have an EMR. Seriously, the Bureau of Weights and Measures. These standards should be developed with input from the hospital industry, physicians, midlevel providers, nurses, and database engineers specializing in intercommunicability and security. This standards-making process should actively exclude representatives from the current EMR companies. The process should pay no mind for backward compatability concerns. These are the assholes who jumped the gun in the first place and forced us to buy dangerous, flawed products at exorbitant prices. Screw ’em.
Step 3. Require commercially offered EMR programs to be tested and certified by the FDA as a medical device. You think I’m kidding? I’m not kidding. The EMR is a medical device, a device that affects every single patient care interaction. A bad EMR is dangerous to patients. If the FDA requires that my felt tip skin marker be certified before I use it to mark a patient, yeah, I think they should check to make sure that the EMR doesn’t systematically screw up my orders. Not such a crazy concept. Oh, and the current multibillion dollar products already on the market should be retroactively required to pass this testing. No grandfather clause here–these programs are flawed and dangerous. Let the FDA sort it out by soliciting open comments from the consumers (that would be us). They will be swamped with helpful information.
Step 4. Governmental funding of a standard EMR to be made available to any and all practioners/healthcare facilities at no charge. This whole EMR idea began when a bright young (or maybe not so young, I wasn’t there) physician stood up (might have just raised his hand, not sure) and pointed out in a committee meeting during the early ’90s that the VA system had this pretty cool computer system that was better than paper charting. Say what you want about the VA, they were the first and the best at this EMR stuff. Then we all said, yeah, that sounds great, let’s do for the country what the VA is doing for our vets. Which, of course, we completely screwed up. So I propose that the federal government pay the money to improve upon the VA program to develop a simple, effective, broadly applicable, safe EMR. Then the federal government should make this program available as the minimum default option for any and all health care practitioners and facilities for free. Because we paid for it already with our tax dollars through VA funding. This program, of course, wouldn’t be the “bells and whistles” pretty thing that private industry will provide for profit. But having this free product would establish a baseline that all the other manufacturers will have to exceed if they expect us to lay out a lot of our hard-earned cash. Because right now we’re paying for a grossly inferior product.
I can already hear my Malthusiastic colleagues and trade group lobbyists saying that these recommendations are bogus, just more government regulation/interference with the free market, blah, blah, blah. Hey guys–we tried that, and we got this. So no, it didn’t work. Mandating purchase of a product immediately disrupts the free market. Believe me, if we weren’t forced into it, very few of us would’ve purchased the grossly defective products currently on the market at extortionist prices. The free market will be effective at leading to competitive pricing of an improved product if we take away the threat of near-term penalties and establish standards for this medical instrument. Then, and only then, can the free market work its magic.
I urge my colleagues, representatives, and medical societies to take up this challenge. Nothing in our current practice of health care is more important.
Sequel to Automated Malpractice and Digital Dishonesty, the first in a series dealing with the disaster which has befallen our health care system.
The single, most powerful tool employed by every physician in the care of patients is the medical record. It is the tool that impacts the care of every single patient. It is the tool that makes difficult diagnoses possible. It organizes and makes possible treatment modalities of every type. It allows collaboration between multiple health care practitioners. It prevents redundancies, harmful treatment interactions, errors in therapy. It makes possible quality improvement. It is the basis of clinical research and the datum upon which discoveries are made and ineffective treatments eliminated.
The medical record is the fundamental instrument of all patient care.
Take away the medical record and you might as well eliminate the use of antibiotics, of vaccines, of anesthesia, of blood typing–because every aspect of these treatments and their safe implementation requires an accurate, accessible medical record.
We are currently in the process of destroying the patient medical record as an accurate, dependable tool in the care of patients. As a direct consequence of our current actions, patients are being harmed. Quality assurance programs are being compromised. Future research will be flawed.
This phenomenon is being witnessed across every aspect of medical practice and in every patient care venue in this country. It is being experienced by every physician, nurse, and allied health care provider. It is incontrovertible. It is, quite simply, a national disgrace and a health care emergency.
The previous system of writing notes and orders with a pen in a paper chart was flawed, of course. It had the drawback of being, on occasion, uninterpretable. This led to errors. It had the drawback of being difficult to access. This led to inadequate communication, redundant testing, inadequate treatment. There was a definite and defined need for a better system. No one would argue differently. The new system needed to be:
i. accurate, ie., legible
ii. accessible to all patient care providers, including physician offices, emergency departments, hospitals, clinics, researchers, auditers
iii. systematically better than a bunch of pieces of paper stapled together: that is, it should intrinsically avoid dosage errors, medication conflicts, redundancies, etc.
Obviously, the new electronic medical record should be better than paper. Paper required health care practitioners in the form of nurses, PA’s, and pharmacists to interpret a physician’s desires and catch our mistakes before they reached the patient. If I ordered an antibiotic for a patient and the patient had a history of allergy to that antibiotic, a key patient fact that I was not aware of at the time of treatment, I relied on a clinically astute nurse or a pharmacist with the patient’s allergy flag to catch it and stop me before I injured the patient. Obviously, this was a problem, because some nurses and pharmacists, just like some physicians, are more experienced, conscientious, knowledgable, and savvy than others. Better to have a system that automatically and consistently checks every order against the patient’s documented record for such a life-threatening conflict.
The intent, at the national/governmental level, was to create and mandate the implementation of just such a system, a system to address the known failings of the existing paper-based system and improve patient care. But the reality rapidly superceded the intent. Through a tortured labyrinth of governmental committees and corporate boardrooms, we allowed the private, profit-motivated sector to leap into the gap between good standards and mandated implementation. In retrospect, we all should have seen this coming from many miles away. A government mandate that would require the purchase of a product by every doctor, hospital, and clinic in America? How much was that worth? Obviously, a great deal. So why wait for standards? Why develop a good system, a worthy product, when we can beat the competiton and sell a cheap, untested, poor product and require these guys to buy it whether they like or not, whether it works or not, even if it’s intrinsically dangerous?
Which is how we arrived to the point we find ourselves at now. Hospitals, physican practices, and clinics have been forced to expend millions of dollars to purchase poorly designed electronic medical record systems. Physicians across the country are now required to spend dozens of hours training up on a variety of unstandardized systems. They are required to become facile in the care of patients utilizing deeply flawed instruments that do not approach the minimum level of quality to allow safe patient care. The problems exhibited by the current state of the governmentally mandated art range from the simply irritating, to the amazingly stupid, and all the way to the point of the systematically murderous. I do not exaggerate. Allow me to provide examples:
The simply irritating: Each hospital at which I care for patients has its own brand of electronic medical record (EMR). Each EMR requires a unique user name and password. But some of these hospitals also have a separate system for charting in their Emergency Department. Many have a separate system to access electronic ordering, or another system to view radiology images, and another system to complete medical records, and yet another system to access labarotory results. Additionally, a separate system exists for electronic prescribing (also mandated), not to mention the required State Narcotic Abuse Database Access, also with a unique user ID and password. None of these systems, user names, or passwords are centralized or mutual in any way. And in the name of patient security, every one of these systems requires that I change my password every thirty to ninety days. But not in the same thirty day cycle. And not to anything that remotely resembled my previous password. Which leads to the constant juggling of multiple passwords with no chance of providing anything near efficient patient care. Maddening.
In those practices that require efficient clinical care, the implementation of the EMR has been uniformly disastrous. Patient office visits are now characterized by a screen interposed between the patient and the clinician, eye contact being a thing of past. Documentation is terse, inadequate, and often plain untrue. Most opthamologists and many other physicians have been forced to hire a new category of health care worker, the EMR documentician, to follow behind the physician and enter information into the computer. This has led to enormous additional expense and a new avenue for inaccuracy. I routinely hear from my colleagues how they have to spend their evenings at home doing EMR documentation from the patients that they saw during the office hours earlier that day, as if anyone could expect to recall the subtleties of dozens of patient interactions six hours later. Simply insane.
Amazingly stupid: Two of the hospitals I work in utilize the Allscripts EMR system. This system features the amazingly stupid feature of not superceding previous orders when such a feature is obvious and required. The diet order is a case in point. When a physician enters a diet for a patient, the previous diet order should be stopped. But no, this is not the case. So my patients routinely have several, conflicting diet orders running contemporaneously. I have discussed this on over a dozen occasions with the IT department, the physican IT laison, and presented to the IT/Patient services committee. No patient, I explain repeatedly, ever needs more than one diet at a time. They all patiently explain to me that such a change is not possible in this system. So my patients routinely receive trays for clear liquid diets, full liquid diets, regular diets, specialty diets, all at the same time. We depend on the dieticians to sort this all out on a daily basis. The waste in effort and food, not to mention the costs associated with cancelled procedures and the morbidity of inappropriately administered diets, is intolerable, but apparently unfixable with the current state of technology.
Systematically murderous: As I have mentioned, the key to good medical care is the conscientious application of patient information to allow informed decision making. The old system of paper charting was deficient in this aspect. A new, electronic system, should permit artificial intelligence applications to prevent many common errors, such as administration of inappropriate medications, wrong dosage, or duplication of treatments or testing. The system should be designed to enhance patient care and safety. Instead, we have a system that actually decreases patient safety and requires constant vigilance on the part of all health care providers to prevent system-incurred errors. This is the exact opposite of what is needed and appropriate, but it is happening constantly. In the postoperative setting, needed DVT prophylaxis medication is often ordered, but the system fails to reliably discontinue the same prophylaxis order from the preoperative period. This results in two or three doses of the blood-thinning medication arriving on the floor for administration to the patient. Usually, the nurse is sharp enough to detect the duplication and send the extra doses back to the pharmacy, but if there has been a shift change or breakdown in communication, extra doses may be administered with resulting complications. The system must be designed to make us better, not require us to police new, intrinsic challenges to good patient care. The current situation is unacceptable.
Not to mention, medicolegally compromising: One of the nationally implemented EMR systems fails to close out patient encounters when the patient is discharged. This leads to the occasional situation wherein a treating physician accidentally places multiple orders into the system for a patient, not realizing that the orders are being entered into a patient encounter that is no longer appropriate. There is no systemic prevention for such an error. So in the middle of the night when an emergency patient requires admission to the ICU or is to be taken emergently to the OR, dozens of orders are entered, but not implemented. The physician is told that his orders are missing, so he or his associate/resident/PA re-enters all the orders. But now there exist a slew of orders added to a past encounter that were never acknowledged or administered. Lord only knows what will be made of that when the chart is eventually reviewed for quality or legal concerns. Good luck with that in a court five or six years after the occurrence.
What is obvious from the foregoing tirade is that the current implementation of the mandated EMR fails to meet the minimum requirements that I laid out in the beginning of this post. It is legible, but it is inaccurate. It is not accessible, due to a complete lack of interoperability standards. As a system, it fails to improve patient care, but rather introduces an entire new class of systemic challenges to good, safe patient care. The current system is simply unacceptable. In the next post, we will discuss the remarkably simple solution to the current situation.
Yes, this (in anticipation of my upcoming series of blog rants on the state of clinical medical publications):
My previous post discussed the myths surrounding the “replication crisis” in psychology/neuroscience research. As usual, it became way too long and I didn’t even cover several additional points I wanted to mention. I will leave most of these for a later post in which I will speculate about why failed replications, papers about incorrect/questionable procedures, and other actions by the Holy Warriors for Research Truth cause such a lot of bad blood. I will try to be quick in that one or split it up into parts. Before I can get around to this though, let me briefly (and I am really trying this time!) have a short intermission with practical examples of the largely theoretical and philosophical arguments I made in previous posts.
Science is self-correcting
I’ve said it before but it deserves saying again. Science self-corrects, no matter how much the Crusaders want to whine and claim that…
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This post was to be entitled, “You Drive Like a Dick,” but hey–it’s the holidays. And in case you haven’t noticed, people drive even more dickishly (copyright, ERG) now than at other times of the year. Hence, the new title.
In keeping with the holiday spirit, it is my considered opinion that people are now driving worse than ever. Both of the regular followers of this blog know that I have a bit of a petulant streak when it comes to my fellow drivers, e.g.., “Overcourteous Assholes Like Me.” Last year, I was irritated. This year, I fear for my life. This year, a new classless class of drivers has appeared, a class that adheres to the following three point credo:
I. The rules of driving apply to you, not to me.
II. Get out of my way.
III. My car/truck is a two ton steel weapon on wheels which I am willing to use to injure, maim, or kill if you slow me down or generally do anything that pisses me off.
I refer to this new class of driver as “sodding slugfucks.” But not to their face. This is why I don’t refer to these people as “sodding slugfucks” to their face: Detroit Driver Shot in Face in Road Rage Incident. If you have ever been tempted to get out of your car to discuss driving etiquette with someone, this article will surely disabuse you of that silly notion. Please don’t.
It has come to my attention that otherwise reasonable people can and do behave like sodding slugfucks when they drive. I know this, because I live on an island. When you live on an island, you occasionally find yourself in a situation of being assaulted by a sodding slugfuck while driving, only to subsequently realize that both of you are driving to the same destination. On one occasion, that destination turned out to be our mutual place of employment. We parked next to each other. Somewhat awkward. On another occasion, the sodding slugfuck cut me off, tried to hit me, then screamed at me through my window before we both ended up in my neighborhood, only to realize that we live on the same block. Even awkwarder.
With the foregoing in mind, perhaps it would be a holiday mitzvah to point out the type of activity that may lead to the realization that even you may be acting like a sodding slugfuck. So you can stop. As kind of a public service, I offer the following:
–Over the last six months, I have witnessed several guys who, in the middle of the day and at a busy intersection, decided that waiting for a traffic light to turn green was for losers, so they proceeded to just sprint across the intersection against the light. This causes every other driver to screech to a halt, wondering what the hell just happened and whether civilization as we know it has come to an end and nobody told us. If you were one of these guys, and you didn’t jump the light because your wife was in active labor at a nearby hospital, then you, sir, are a sodding slugfuck. Don’t do that anymore.
–I still pull over when I see an ambulance, lights flashing, come racing up behind me. Call me old-fashioned, I know. Other drivers may just drive faster to try to stay ahead of the ambulance, but last I checked that was kind of against the law. What I’ve noticed now with frightening regularity, however, is that once the ambulance has passed, some sodding slugfuck (sometimes a whole string of sodding slugfucks) is chasing so closely behind the ambulance that I’m nearly killed when I try to pull back into my lane. Unless you are related to the poor sap in the back of the ambulance, if you don’t let me back into my lane because you’re speeding behind the ambulance, you are a sodding slugfuck. Or an ambulance-chasing lawyer, in which case you are also a sodding slugfuck.
–It appears that many drivers incur physical pain if they are required to use the brake while driving. This must be some type of new epidemic, because I witness this ailment at least a half dozen times a day. The symptoms are evident when a car slows to make a right hand turn and the car behind, instead of braking slightly to let the guy turn, swerves around him into the left turn lane. Or in my recent experience, across the double yellow line to nearly hit me head-on, requiring me to veer off the road and almost hit a tree. Main Street in my little hamlet is not the Nouvelle Chicane in Monaco, okay? If you do this, please stop being a sogging slugfuck. You’re going to kill someone. Maybe me.
I could go on, but it’s the holidays. I’ll save the rest for next year–like how your horn doesn’t make all the cars stuck in traffic ahead of you magically disappear. Really.
Happy Holidays. Don’t Drive Angry!
For my fellow F1 followers, the following (and no, I won’t be reblogging anything about Rosberg):
I’d expected him to look older. I suppose its only natural with someone you’d been reading about for years, but he’d been such a constant part of the motorsport landscape for such a long time that I’d imagined he’d already be the finished article. He’d been a mini-megastar in England since his karting days. Even as a child I remember seeing his face on TV, on the news, on ITV’s karting show with DJ David ‘Kid’ Jensen, Blue Peter, through the pages of Autosport and Motoring News. He was a future world champion. That’s what we’d always been told. That’s what we’d always believed. And here he was, this future F1 superstar. I’d expected him to be taller. I’d expected him to be broader… I’d expected him to look older.
But there he stood on the pitwall in his ASM F3 overalls, a…
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