Difficult Doctors

Difficult doctor (def): a physician that disagrees with, or fails to immediately and graciously comply with, the expressed directive of any nurse manager or hospital administrator. [cf., Policy relating to the Reporting and Disciplinary Procedures for Difficult Doctors]

Many of you are painfully aware that our work environment has recently become–how best to phrase it?  Silly? Unpleasant? Challenging? Flat out, batshit crazy?  Yes, let’s go with that last one. (See Doctors Without Barbers). And I’m not even going to grace these new policies with any discussion, because they are so imbecilic as to not merit even this amount of attention.

(Doctor, you can’t leave the OR without a jacket. The short, paper one. No, no, no, doctor, not the full length disposable one.  Oh my god no, not the full length disposable yellow one, that’s only for isolation and an alarm will go off if you walk out of here with that on. Wear this one, it’s required, but make sure to take it off and replace it with the full length disposable one you had in your hand a minute ago if you step into the hallway with the brown guardrail to tell the family that your patient survived their operation, then take the full-length but not yellow one off and put the short coat back on when walking between the brown railed hallway and back to the OR, then remove the short coat before scrubbing for your next surgery but you can’t don a surgical mask after donning your coat because that would lead to shedding of dangerous skin cells onto the coat, rendering the entire environment a potential health hazard but you can’t go into the OR without a mask and you can’t walk down the hall with a mask dangling on your chest and you can’t walk down that hall to get a mask without the coat on so I guess you’ll just have to not operate any more today, okay? Sorry, doctor, it’s the policy. Have a nice day.)

Those in  the business know that I’m not making any of that up. Really.

Dread_Pirate_Roberts_by_bryanhumphrey

So, I received the following email recently from our hospital administrator:

Dear Surgical Physicians, Nurses, Techs, and all Operative Colleagues:

As you are aware, our policy for Surgical Attire is based on National Standards, and was developed to ensure our commitment to Patient Safety , which remains our core value.  In addition, proper surgical attire continues to be a major focus for both CMS and the State Department of Health.  Unfortunately, many of our sister hospitals (as well as hospitals in other systems) have found themselves in a position where physicians and staff members were not following policy to the specified level, and were subsequently placed on periods of Immediate Jeopardy, in which they were at risk of losing their Medicare and Medicaid funding.

We are doing everything we can as a hospital to follow our policy and avoid situations such as that.  I am attaching our Surgical Attire policy as a refresher of the expectations at [our hospital].  At the current time, I will remind you that ALL hair is to be covered, including sideburns and hair at the nape of the neck, as well as any facial hair (i.e. mustache).  Our strongest recommendation is that to make it most easy for you to comply, surgical hoods should be worn, often in conjunction with a surgical cap, to allow maximum of hair coverage with minimal effort.  Mirrors have been added around the operating theater to allow each physician and staff member to best police themselves.

You are all professionals, and your professional obligation is that you will comply with hospital policy.  We will be conducting periodic observations to make sure we are compliant.  I would ask that all staff please look to help any other physician or staff member who has not noticed that there is errant hair, or other non-compliance with the policy.

I am confident that we, as a hospital, and YOU as the Operative team, will be compliant and successful.

Sincerely,

[name deleted]

Vice President Medical Affairs & Chief Medical Office

 

So much of what is wrong with our current OR work environment is summarized in this completely nonsensical email.  Let’s discuss:

“As you are aware, our policy for Surgical Attire is based on National Standards”–actually, no, it isn’t.  It is an ungrammatical, unscientific, ad hoc mash-up of AORN policy recommendations, in-house silliness, and a good bit of complete nonsense.  It has no basis in JCAHO or Department of Health standards. It directly contradicts recommendations by many national and international scientific organizations, including the American College of Surgery Manual of Perioperative Care and a recent policy statement by the ACS. There is nothing about it that even approaches a rational scientific basis or accepted standards, national or otherwise.  It in no way represents any form of consensus of surgeons, nurses, or surgical technicians, either within the institution or at the level of representative organizations.  It was authored by a couple of nurse administrators who haven’t seen the inside of an operating room in decades while sitting in a hospital conference room with a few administrators lacking any clinical insight whatsoever and absent any physician, anesthesiologist,  or surgeon who might contribute rational insight into the process; i.e., dissent. The resulting policy was then filed in the Manual of Procedures and Policy without benefit of review by the Chief of Surgery, his designate, the OR committee, or as an agenda item at the surgical departmental meeting.  Or by the Chief of Anesthesia, or at the anesthesia departmental meeting. Or by the Chief of OB/Gyn, or at their departmental meeting. Or by the Chief of Orthopedics, or at the ortho departmental meeting. Of course it wasn’t, because the physicians affected would’ve pointed out that the document was nonsense. They would be “difficult.”

“developed to ensure our commitment to Patient Safety , which remains our core value”–unfortunately, your core value has been repeatedly demonstrated to be maximizing revenue. Capitalizing the phrase “Patient Safety” in all official emails does not make it your priority. You have an amazing capacity to re-interpret your institutional commitment to Patient Safety if this proves too expensive. It just so happens that arbitrary rules regarding surgical attire costs the hospital nothing.  And by the way, if you truly believe that the type of hat worn by a surgeon or OR nurse is an issue of patient safety, you really shouldn’t be allowed to come to work as a hospital administrator.

“Our strongest recommendation is that to make it most easy for you to comply, surgical hoods should be worn, often in conjunction with a surgical cap, to allow maximum of hair coverage with minimal effort.”–of course, this recommendation makes no sense, which is obvious to anyone who has actually set foot in an OR, and creates a situation in which you will be unable to operate, or keep from sweating into your patient’s wound (recent policy change takes away the ability to control OR room temperature without contacting an administrator), or breathe. We’re just interested in making it “most easy for you to comply.” Comply or die, whatever. Minimal effort.

“Mirrors have been added around the operating theater to allow each physician and staff member to best police themselves.”–I have no words.

“I would ask that all staff please look to help any other physician or staff member who has not noticed that there is errant hair, or other non-compliance with the policy.”–Please report your fellow workers to the authorities. You may be awarded the coveted “Employee of the Month.”

And more recently, yet another hospital email regarding this same subject ended with the following threat:

Please review the attached Guidelines for Operating Room Environment and Surgical Attire Policy.

Non-compliance with our policy will compromise the Hospital’s position with the DOH and may lead to financial penalty for the Hospital.   For physicians who are found to be in violation of our policy, a ‘non-adherence to policy that compromises patient safety’ note will be placed in the credentials file as part of their OPPE.

So, it’s okay that the OR nursing supervisor is “surprised” to realize that my hospital has no CO2 cylinders available when the tank goes empty halfway through my laparoscopic procedure, which results in no incident report, meeting, or repercussion of any sort, but if I fail to wear a disposable short coat while walking between the OR and the recovery room I will be cited as “compromising patient safety.”  A note will be placed in my permanent record.

Seriously.

 

Anesthesia is Pretty Difficult (5)–and Reading Can be Hard, too

Anesthesia is the scientific study of the subtle screw-up.

Same anesthesia rotation, different day, same inappropriately confident practitioner (me) today assigned to the gentle care of an eighty-two year old gentleman scheduled to undergo a routine hernioraphy.  Did I say routine?  Why yes, I did.  Hell, people, we do this shit a thousand times a day, let’s put this truck in D and get this done…BgicidBCQAAGm96

First case of the day, I’m a little late arriving to the break of dawn party that is the OR at this fine Midwestern University Hospital (17 year old Vega only starts by popping the clutch as I roll downhill), surgeon is annoyingly early and already pacing about, giving me that smile and saying, “Hey, take your time,” which means “Move your ass or I’m filing out this ‘Reason the Case was Delayed form.’ ”  I’m moving my ass, but this eighty-two year old ain’t a spring chicken, he’s taking about twenty minutes just to assume the position on the OR table so I can put in my obligatory spinal.  (Because, remember, everybody here gets a spinal.)  As Nurse Slowly Helpful helpfully but slowly helps patient curl up on his side “just like a baby or a comma” I’m marveling at her mastery of the mixed metaphor as I run in my mandatory liter of IV saline.  This eighty-two year old is on beta-blockers (who the hell isn’t?) and has the essential hypertension.  I’m about to relieve him of his spinal-cord mediated vascular tone with my spinal anesthetic, so in goes the vascular volumizer in anticipation of this physiological phenomenon.  An ounce–or liter–of prevention, you know.

Finally, the patient is positioned with Nurse holding him with maternal tenderness in fetal/comma position, I’ve got my gloves on and precalculated dose of magic local anesthetic drawn up as I notice Surgeon With No Home Life filling in the blanks of the “Case Delayed” form, but before he can sign illegibly I’ve done my Modified Taylor Technique thing and say, “DONE!” as I dramatically strip off my gloves, standing up to help Nurse  Nurturing reposition elderly widower patient with murmured sweet kindnesses (“See, that wasn’t so bad, was it?”) onto his back and crank the bed into the crazy angle that will give my man here just the right level of unilateral hernioraphy without hurting, perfect regional technique.  I’m thinking that, ‘Not so bad at all, no sirree. Damn, Geller, that guy was calcified and old and scoliotic and that was pretty sweet, first try and boom, baby, I could probably give a spinal to Michelangelo’s David if somebody could get him off that pedestal and lay him on his side for thirty seconds.’ Or something along those lines as I do my post-spinal first set of vitals-BP 176/90-well, you knew the old geezer had the hypertension going in, no problem, spinal will fix that, too.  I check my level and, of course, it’s perfect, so I pointedly announce to Surgeon Suddenly that we’re all set, he can scrub if he wants to get things started, big day of surgery ahead, wink, wink.

As the nurse is prepping the patient, I ask him how he’s feeling as I lovingly apply nasal cannula and he smiles at me upside down and says “Good,” like he knows that he’s in the hands of someone who’s taking really good care of him and he really  appreciates me, so I turn smiling to my drawer of a million medicines and select my little glass ampule of ephedrine from the neat little cubbyhole that is its special home, glance at the label as I crack the top and draw up my “just-in-case, never-hurts-to-be-ready, hell-it’s-not-my-money” pressor and dilute it 10:1, labelled and leave it lying on my little work space.

I’m humming to myself and glancing at the schedule to see if I can use a spinal on the next case (of course I can) as surgeon checks for effective anesthetic by pinching patient with pointed Adson tweezers, I nod at him with a smile as my patient remains oblivious to this assault.  Surgery ensues.  I recheck ancient patient’s BP, now 110/72.  See, I knew that the spinal was working and his hypertension is now normotension and what’s better than that, huh?  I look down fondly on my patient, now realizing that he looks just like the grandfather I never knew as he softly snores in contented comfort.  Sigh.  Isn’t anesthesia great?

“I think I might be sick,” patient mutters and I ask him “Excuse me?” noticing the slight sheen of perspiration on my Grandad’s forehead.  “Just a little queasy,” he says, smiling apologetically and I nod sympathetically as I recheck his pressure and-what do you know?–BP now 98 over don’t bother to notice because obviously it’s on its way down so I spin and push a little ephedrine, because I knew this was going to happen, I’m prepared.  I lovingly dry sweat from my patient’s brow with gauze and give him my reassuring smile but I’m noticing he’s looking a little pasty in his pallor.  Let’s just recheck that BP though it’s only been two minutes since the last one and–what the hell?– his pressure’s eighty?  That can’t be right, I pushed the pressor, should be working by now, let’s try that BP again and now it’s 70 and now I’m the one suddenly nauseous and I feel sweat appear on the back of my neck as I push half the remaining syringe of ephedrine.  I lean over my Poppa and ask, “How’re you doing?”

He looks me straight in the eye and says, “I think I’m dying.”  He seems sincere about this.  I check his BP, which is now somewhere south of seventy and I’m forced to agree with his clinical judgement.  A cold trickle of sweat runs down my back as I call my attending.

Kindly attending anesthesiologist appears and is immediately concerned when he sees the abject fear in my face.  “What’s up, Geller?”  Well, I explain, not my patient’s blood pressure though it should be because I’ve given him all this ephedrine (I hold up nearly empty syringe) but his pressure just keeps dropping and he thinks he’s dying and he looks like crap and I think he might be right and–

“Hold on.  You gave him ephedrine?’  I nod.  “Show me.”  I hand him the syringe.  “No, show me the vial you drew this up from.”  I look around and find the vial in the little plastic can attached to my cart and hand it to him as I sweat semicircles under my arms.

“Everything okay up there?” Surgeon asks, looking over the drape at our little tete-a-tete.

“Sure, no problem,” Anesthesia Attending reassures.  He turns to me and shows me the vial.  Sotto voce, he says to me, “This isn’t ephedrine.  It’s chlorpromazine.”

“WHAT?  Of course it’s ephedrine, I looked at the label,” I stammer as I look at the vial that says “Chlorpromazine” pretty clearly right there on the label.  No way, I’m thinking as I scan my drawer, noticing for the first time that even though every little vial is color-coded for safety, chlorpromazine and ephedrine just happen to be the exact same color and hey, look at that, they’re also right next to each other in the little cubbies, isn’t that just great, maybe the person who stocks this shit just missed a little in his underpaid, rushing through his job stocking my damn drawer.  Stop, Geller, just think–but I’m having a hard time thinking because the OR just turned to shades of gray and I’m hearing a roaring sound in my ears as I recall from Pharmacology For Fools Like Medical Students 101 in a sudden flash that chlorpromazine is an alpha blocker, strange the little facts that come rushing back from memory, especially since alpha blockade is the exact opposite of what my patient needed, OH MY GOD I’VE KILLED GRANDPA!  I drop heavily onto chair reserved for incompetent anesthesia wanna-be’s and seriously consider throwing up.

Meanwhile, Anesthesia Attending (a man who can actually read a label, not just pass that ampule in front of his face and seem to see it) has swung into action and is giving my patient real ephedrine straight up and wide open fluids and turns to me, saying “Go take a break, Geller, you look like you’re going to puke.”  I nod and take his advice.

When I return, only a little relieved that there’s no code cart outside the door, Anesthesia Attending is smiling.  “He’s fine, Geller.  Actually, I charted your chlorpromazine, he was nauseous, not completely out of line, there,” but I know he’s just trying to be nice.  Actually, it was exactly the wrong thing and it’s only by the grace of God Almighty that I didn’t kill this man.  “Pressure was low there for a while, I think he should stay overnight, maybe check some enzymes, make sure…”  Make sure I didn’t give the guy an MI, he’s kindly not finishing in his sentence.  I nod and thank him as I take over my case again.  Anesthesia Attending gives my shoulder a reassuring squeeze as he leaves with a smile that clearly says, “You fucked that up, Geller.”

I stayed the night with my kindly old grand-dad.  He thought it was a little weird, I’m sure, that this twenty-something year old wanted to hang out and play cards and kept looking at his bedside monitor as he told me about what he did in the war and his kids and a lot of other stuff I don’t remember because I was just so damn grateful the old guy didn’t die on me.

Doctors Without Barbers

Barbarians at the Gates of the OR

It is time for pervasive panic and generalized pandemonium in my little hospital.  We knew we had been fortunate these past few years to remain sheltered in our backwater, unnoticed in the shadow of the huge academic medical center just down the road.  Other hospitals, we know, have faced these trials in recent years, but we had been spared.  We had been a small island of sanity, a redoubt of reasonable people caring for patients with reasonable ways.  No more, however.  Today, wild-eyed administrators are running amok in the hallways.  Nursing supervisors are lining up the cowering minions for inspection of hand washing efficacy like so many orphans from Annie.  Surgeons with heads uncovered are being challenged and so are surgeons with heads covered when the OR nursing administrator explains that all heads must be covered but head coverings must be removed.  Lose that lanyard or lose your life–you’re going to kill somebody with that thing.  I don’t think I saw you wash your hands just now, did I, doctor?  It’s the regulations, doctor.  Please, don’t be difficult, doctor.n

Trouble is at our gates–trouble in the form of the JCA (formerly the JCAHO, formerly the JCAH, the bastard devil-spawn of the lascivious American College of Surgeons and that harlot, the AHA) and the CMS (formerly so many different acronyms as to be unnameable).  Two hospitals in our realm (one being the aforementioned high-towered University Hospital) have been invaded, inspected, and decimated by the event.  Hospital administrators are left weeping and broken in their wake, clutching reams of citations and deficiencies.  Oh, the horror, the inhumanity–the lost revenue.

We will not be taken so easily!  We will be ready. Every effort will be made to put down this new plague.  We will wear garlic necklaces if there’s an article in the Journal of Medieval Medicine  (vol. 3, Sep 1199) that says that such efforts are laudable.  New regulations will be promulgated, old regulations rigorously enforced and any lack of enthusiastic compliance will be judged to be a threat to patient care and dealt with aggressively.  Those who do not comply will be reported to the committee we have for just this sort of thing.

There is only one problem–none of this zealous response has anything to do with the care of our patients.  Just the opposite, unfortunately.  Patient care is compromised amidst the capricious, unsubstantiated and unjustifiable new policies; policies that are conceived and become doctrine at administrative levels carefully removed from the influence of those difficult doctors who just won’t go along with anything.  New policies appear as dogma based upon AORN guidelines–but now that they are written down on hospital computerized stationary, take on the rule of law.  No matter that none of these guidelines approach the level of standards or regulations, that the JCA never required compliance with these phantom statutes, that there isn’t the faintest whiff of science or rationality behind them.  All hair is to be covered, so, yes, doctor, you are going to have to shave that off for the good of the patient. Do you want your patients to suffer a horrifying septic death and skew our hospital statistics?  Is that what you want?  I’m sorry, doctor, but if you’re not willing to put the welfare of your patient above all else, well–I’m very sorry to say that I must report your lack of enthusiastic compliance to the Committee to Deal With Combative, Aggressive, and Inappropriately Behaving Physicians Who Have a Bad Attitude.  Isn’t your ex-wife on that committee, doctor?  Are you sure you wouldn’t prefer to just wear one of our ‘full-coverage hoods’ and sit quietly in the OR lounge?  I thought you would, doctor.  Smile, doctor–the patients get upset if the staff isn’t happy, you know, and patient anxiety has been proven to have a negative effect on wound healing.  I know, nobody can see you smiling in that hood, but it’s really your entire attitude, doctor, that is really the important thing.  Don’t you agree?

Electronic Medical Death

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:

How Medical Tech Gave a Patient a Massive Overdose

This type of manzanita grows in the San Luis Obispo region of California

Next time, we’ll explore this aspect of EMR implementation further.

Let’s Have an EMR That Doesn’t Suck: Part 4

 

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?Minolta DSC

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.

Exorcising the Demon of Digital Documentation: EMR Part 3

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:

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.

.Minolta DSC

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.

Death by Electronic Medical Record Keeping: Part 2

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.IMG_1302

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.

Doctors Parking

I’m old enough to remember when physicians in general–and surgeons in particular–were held in high regard.  I mean, we used to have our own parking spaces and free coffee in the doctor’s lounge.  I remember when I was a resident in surgical training being taken to lunch between cases by my surgical attending at the hospital’s designated doctor’s only lunchroom, served a steak and fries by a waiter, then encouraged to finish my drink before running back to the OR to get the next patient ready for surgery.  And this was an inner city, midwest academic hospital! Table cloths and linen napkins!  I’m not making this up–it was the eighties.  Now that I’m an attending surgeon myself, I usually find myself wolfing down an Odwalla bar with cold coffee between cases. So I’m sensitive to the situation when one of my surgical colleagues is bent over the hood of a car, in handcuffs, with several guns pointed at him. How did we get to this?

MB2

Because, I hear you saying, you guys act like greedy, pompous dicks.  And while you are right (see “Mommas, Don’t Let Your Babies Grow Up to be Surgeons” for a start), that’s not the exact explanation.  Doctors used to run the hospital–literally and figuratively. In the twentieth century, successful hospital administrators were either grey-haired physicians who realized that the most important thing a hospital did was take care of patients, or no-nonsense nuns with MBA degrees who wouldn’t let anybody die in their facility, goddam it.  By the turn of the century, however, hospitals became “Medical Centers of Excellence” with “Program Initiatives” and extensive real estate investments, even the occasional shopping mall amidst the medical campus.  The CEO had bigger concerns than relieving suffering and curing disease, he had a big bottom line and a board to answer to.  That patient care stuff was delegated to a third-tier hospital administrator who could be found cowering in a windowless office, apologizing to the Chief of Cardiac Surgery for not getting his shiny new hospital wing finished on time, begging the surgeon not to make good on his threat to bankrupt the hospital by taking his skills across town.  Now the third-tier hospital administrators take home million dollar salaries as they lay off all the experienced nurses in that same, now careworn cardiac wing, because of the need to “trim the service line overhead.”  The center of power has shifted, you see.  Today, the Chief of Cardiac Surgery finds that his ID badge doesn’t even open the doors to the administrative wing.  And that’s where the nice cafeteria is.

Not so many years ago, I used to make a habit of leaving the hospital on my way home by walking out through the Emergency Room.  You learn after a decade of being the Chief of Trauma Surgery to look for trouble on the way out, because otherwise you had a pretty fair chance of getting called back in half an hour.  So on the way out I’d walk through the resuscitation bays and exit through the ambulance dock.  On one occasion, I was walking out this way when I noticed that a number of hospital security personnel were surrounding an individual, guns drawn.  The university had only recently granted our security personnel permission to carry weapons, and it wasn’t unusal at this time to see them working through the particulars of just when to employ their new, shiny Glocks.  It was dangerous to drop a candy wrapper in the lobby or complain too vocally about the lack of parking spaces.  So on seeing this little armed tableau, I just kept walking, somewhat ignoring the guy bent over the hood of his car, screaming obscenities.  I stopped, however, when I recognized the man’s voice.  That, I recall thinking, sounds like my colleague Mark.  Mark was a busy and talented surgeon who operated at several hospitals in the area.  I looked over.  Damn, I thought to myself, that looks like Mark, too.  I walked over to see a man struggling and cursing as he was bent double over the hood of a black Mercedes, being handcuffed by hospital security.  It was Mark.

“Mark,” I said, “what’s up, buddy?”  I noticed at this point that the big black Mercedes, Mark’s car, was parked on the helipad.

“Please stand back,” one of the security guys with his gun drawn admonished me.  “This is a dangerous situation.  I have to ask you to please step back, sir.”

“Geller, is that you?” Mark asked, his face being pressed into the hood of his car.

“Yeah, Mark, it’s me.”

The security guard waved his gun.  “Step back, sir.  Last warning.”  I’m not sure what he meant by that, so I stepped back.  He had the air of being the man in charge.

“Tell these assholes who I am, Evan!” Mark yelled.

“Do you know this man?” security guy asked.

“Maybe.  What’s going on, officer?”  They love to be called officer, because none of the security guys are real cops, you see.  They really, really, wanted to be real cops.  The guns helped.  New cars with the flashing lights also helped.

“Is he a doctor?”

“Might be a doctor,” I said.  “Why, what’d he do?”

“He tried to kill one of our officers,” the security guy explained.

“I just needed to park, so I could do a case!” Mark yelled over.

As I was later able to put together, it turns out that Mark was called to take care of a young patient with appendicitis.  When he got to the hospital, however, he couldn’t find a parking space in the ER lot or the designated doctor’s lot.  Being Mark, he elected not to pay to park in the visitor’s parking structure, deciding instead to park his black Mercedes 500 on the helipad.  This, it turned out, had made it rather difficult to land the helicopter with incoming trauma patients, so security had been called.  Mark finished his case and came out to see his car about to be towed so, being Mark, he got in his car. Being Mark, he assumed that this would resolve the problem.  ER security guy stepped in front of his car.  It seems that security guy, gun drawn, had decided that the goal was not so much to clear the helipad for the transportation of incoming trauma victims, as it was to make Mark pay for his effrontery by having his rich doctor car impounded.  At this point, Mark decided the wisest course of action was to drive away and hope everyone would just forget the whole silly episode, but unfortunately this involved nudging the officer gently with his large, black Mercedes.  Which quickly escalated to a lot more security guys with guns drawn deciding to arrest Mark’s rich doctor ass.

Once I understood exactly what happened, I had to explain to the security guy that no, I don’t think I know the guy after all.  Looked familar, but not the guy I thought he was.

And that’s kind of why things have changed for us doctors.

 

Mammographic Misery and the Plight of the Perpetual Patient

Mammograms save lives.  Despite several controversial studies over the last couple of years, there is no question in my mind or that of most other health care professionals that annual screening mammography for women over age forty has completely revolutionized the treatment of breast cancer.  Those studies can’t claim that people regularly receiving mammograms don’t have better rates of survival or cure from their disease–they claim, with mixed success, that providing a large population of women with mammographic screening is not cost effective.  What price a life, you ask?download

When I began performing surgery for patients with breast cancer in 1982, the typical patient presented with a mass she had felt herself.  By the time she came to me for surgery, her cancer was often in a relatively advanced stage.  Surgery involved complete mastectomy, usually with the removal of large numbers of her underarm lymph nodes, too often leading to disability and disfigurement.  This was followed by chemotherapy and radiation therapy. Worst of all, survival rates in this group of patients rarely reached 80% for the five years following surgery.

Fast-forward to my current practice.  Over 90% of women referred to me for surgical treatment of newly discovered breast cancer are now presenting with a lesion found on their annual screening mammogram.  Almost all of these lesions are about the size of a pea or smaller, having been discovered years before they grew to a size that could be felt on examination.  These early cancers have not spread to the patient’s lymph nodes or anywhere else in her body. There is no need for mastectomy to achieve a complete cure from this early stage of cancer.  Indeed, I can reassure patients that equivalent cure rates for such small cancers can be achieved by a small lumpectomy and a sampling of one or two lymph nodes, a procedure that takes less than an hour.  The patient is home later that morning and experiences minimal discomfort.  Newer forms of radiation therapy permitted by such early diagnosis expose only the localized tissue and can be achieved in five days, rather  than the whole breast radiation therapy over 4 to 6 weeks required in the past.  Most significant of all, this minimal therapy now provides cure rates well over 90% in these early stage patients.

All of this revolutionary success in the treatment of breast cancer has been made possible by earlier diagnosis due to routine screening mammography.  So don’t buy the hype–there is no controversy amongst practitioners over mammography:   A mammogram once a year can save your life.

But that’s not what this post is about.

Let’s talk about what happens after:  After that excruciating moment when I tell you that the biopsy showed cancer.  After the discussion of what we need to do, how soon we can do it (“Sorry, not yesterday”), what happens after the surgery.  Surgery for the treatment of breast cancer is safe, straight-forward, and relatively painless.  To be honest, surgery for breast cancer is the easiest operation I do.  Patients usually are surprised by their rapid recovery.  They come back to my office a couple of weeks after surgery feeling great.  Over the next several months, I see the patient as she completes her recovery and any additional therapy that’s recommended, usually a short course of radiation therapy and a daily estrogen-blocking pill.  By six months after her diagnosis, she’s feeling great and has her life back.   And then reality sets in:

The reality being that you are not really convinced you’re cured of cancer until the moment you die of something else.

We’ve moved from a paradigm of the valiant patient bravely battling her cancer to the successful breast cancer survivor–who now must live forever with her diagnosis.  It’s not a battle with cancer.  Battles are fought and won, and then we can move on. You don’t just fight cancer–you survive cancer, and then you live with having had cancer. This is a burden that few who have not experienced the diagnosis, or lived with someone who has survived cancer, can appreciate.  It doesn’t matter how great you feel, or how many times the doctors say that you’re doing great, or how great your spouse or friends say you look–you worry.  You worry every day.  Because you remember feeling pretty darn great just before the doctor told you that you had cancer.

Of course, we all worry about getting some disease or another.  We worry about that dark mole on our arm that might be a little bigger, particularly after we hear of a young friend recently diagnosed with melanoma.  We worry about heart attacks, because we get chest pain every time we eat Taco Bell or palpitations at the gym.  It’s not the same. It’s not the same because you’ve never been told by the doctor that the biopsy is positive, that your worst fear when you walked into the office was true.  You’ve heard of Post-Traumatic Stress Disorder?  This is Post-The Test Was Bad And You’re Totally Screwed But Now You’re Finally Better Stress Disorder.  And it’s every bit as bad. Maybe you didn’t experience faceless bad guys shooting bullets at you in Iraq, but you experienced some pretty heartless machines shooting xrays at you every day for a couple of months, or smiling nurses apologizing as they stabbed the needle in your vein for the third or fourth time, or watched the strange colored fluid dripping into your body knowing that in 24 hours you’d be doubled over the toilet vomiting because that’s just how this stuff works.  Cancer sucks, and it doesn’t stop sucking just because everyone tells you that you’re cured.

Sure, they say you’re cured.  But you don’t really believe it.  You don’t believe it because we keep sending you for more tests and more mammograms and more CAT scans and more PET scans.  If there were a PUPPY scan or a CUTE FUZZY BEAR scan, we’d send you for that, too.  If I’m cured, you keep wondering, why do we keep looking for it?  And every time you have to go for the test, it’s an opportunity to relive that special feeling you had that time when the test came back bad.  You relive that feeling for the week before you take the test, while you’re in the machine trying to breathe during the test, and for every single second until the doctor calls to tell you that it’s okay. This time, you think.  It’s okay this time.  The elephant steps off your chest–but he doesn’t leave the room, he just steps behind you for awhile.  Until the doctor says that it’s time to do another test.  And there is always another test.  If I’m cured, you think, why do we have to keep looking?

So here we are:  Surviving today.  The test was good.  Enjoy it.  You can run faster than any old elephant.