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.

Medical School, Part 2: The William O. Lombard Memorial Lecture on Flatus

As mentioned in Part 1, the medical school I attended was of the classic, old-school mode.  Like all the great medical schools before it, the “University Of” medical school required their students to spend the first two years of education reading approximately two million textbook pages and attending lectures and labs for over eight hours a day.  Our only clinical, real medicine experience during this time was in the personal discovery of hemorrhoids.  Classic.Minolta DSC

It was tough.  It was effective.  It was boring.  As one would expect of such a prestigious school, the students were smart and hard working.  Having succeeded in undergrad, a large number of the students found they could replicate their approach to their bachelors degree by skipping all the lectures and just reading like a madman, then acing the exam.  As a consequence, attendance was sparse.

The one year course on physiology was no exception.  The lecturer for this course was an elderly, white haired, world famous professor of physiology named Horace W. Rockport, III, or something like that.  He was the author of the most prestigious textbook of physiology at the time, a nine volume tome that was used in nearly every university.  He was a curmudgeon, to put it nicely.  Rockport would stride around the stage in front of the large lecture hall, emphasizing his points by banging his cane against the lectern or the whiteboard behind him.  Visual aids were not employed.  The idea was to sit and take in the grand wizard’s fountain of wisdom.

Rockport was not a shy man.  He lectured with great volume and authority, not only on physiology.  The great one would often include his pronouncements on politics, or society, or the world at large.  He began his lecture on lung physiology with the statement that, “Fully ninety percent of the world’s population performs no notable function other than the conversion of valuable oxygen to carbon dioxide.  That includes you people here, by the way.”  Great guy.

As the year went on, students began to realize that the lectures–besides being misogynistic, racist, and a bit loony–contributed nothing to their education that couldn’t be gleaned from the required reading of the great man’s textbook.  The audience grew more sparse.  This bothered Rockport not one bit, as he often pointed out that he was paid to talk, and he got paid the same no matter how many people were listening.  It became more hazardous to be in the audience, however.  The smaller numbers made for a more intimate experience despite the large auditorium, prompting Rockport to engage students directly, pointing his cane at somebody in the audience and questioning them vigorously.  This was okay when the questions concerned physiology, as we were prepared for that.  We weren’t prepared to answer questions about our parent’s possible infidelity leading to our conception, however.  Or why we thought ourselves smart enough to cure illnesses that God Himself had deemed appropriate to inflict on individual’s who, by this definition, deserved to suffer.  Tough questions.  The audience grew sparser still.

By the end of the academic year, there were about twenty of us left attending the lectures on a consistent basis, out of a class of just over one hundred.  This included the large German Shepard who attended every lecture accompanied his house mates from the medical student commune.  These students had to attend because they had drawn the responsibility of taking lecture notes for the class (at a cost of $100 to each student–I believe these guys went on to become entrepreneurs of narcotic prescription mills in various states).  And me, of course.  I was one of those guys that felt that I had to attend because on my schedule it said “Physiology Lecture 10:00-11:30,” so that’s where I was, usually trying to look inconspicuous somewhere in the middle rows.  I couldn’t sit in the back because the German Shepard did not like me one bit.

Rockport announced the topic of the final lecture with great solemnity, even going to the trouble of writing the title on the white board: “William O. Lombard Memorial Lecture on Flatus.”  He began his lecture with a lengthy and touching tribute to Lombard, a fellow physiologist who had evidently devoted his entire professional career to researching every aspect of the physiology of gastrointestinal vapors.  For some reason which I still do not understand to this day over forty years later, I thought the great wizard was making a joke.  I don’t know why I thought this, as the man had never displayed the slightest sign of a sense of humor during the entirety of the preceding academic year.  “What a sap,” I chuckled appreciatively from the middle rows.  I guess I thought that Rockport meant to contrast the greatness of his own career with that of lesser, mortal physiologists.  I was wrong.  Turns out that Lombard was his friend, or father-in-law, or something.  Never found out exactly what the connection was, but the “sap” comment was noted.

Rockport stopped dead in his tracks.  “Who said that?” he demanded, scanning the large lecture hall.  “It was Geller,” the owners of the German Shepard said.  “Right there, in the middle row.”  Evidently, they felt the same way as the dog.  Rockport rounded on me, jabbing violently from the stage with his cane.  “You think this topic funny, Mister Geller?” he demanded.  Yes, I didn’t say, I find this topic rather ridiculous.  But I just sat and tried not to nod.  “You think the scientific investigation into the nature and physiology of intestinal gases is unimportant?  Not worth your time or study?  Is that what you think, Mister Geller?”  By this time Rockport had come to stand just in front of me, standing at the very edge of the stage and stabbing out with his cane, trying to hit me.  I was, I thought, a safe distance away.  Unless he decided to throw the cane.  Or jump from the stage to attack me.  He had turned bright red and looked like either was a distinct possibility.

“Let me tell you, Mister Geller,” he continued.  “Let me tell you what kind of doctor you’re going to be, unless I can help it.  You, sir, are going to be the kind of doctor that thinks you know enough to get by.  That you don’t need to master the details, do you, Mister Geller?  You’re going to be a gastroenterologist, I think.  Yes, Mr. Geller, a gastroenterologist.  A doctor that makes oodles and oodles of money shoving rubber hoses up the arse of your patients, all day, dozens of times a day, every day.  Getting paid lots and lots of money to shove colonoscopes up the rear end of society’s elite, every day.  And one day, Mr. Geller, one day you’ll be looking up some poor patient’s arse with your fancy colonoscope and you’ll see something!  Do you know what you’ll see, Mr. Geller?”  I had to shake my head at this point, as it was clear he wasn’t going to move on until I did.  “You are going to see a nice fat, juicy polyp, that’s what you’re going to see.  A nice fat, juicy colonic polyp, Mr. Geller.  And I know you’ll want to take out that juicy polyp, Mr. Geller, because you can charge a lot of money to take out the colonic polyps of our society’s elite colons.  So you’ll position your colonoscope, and you’ll ensnare the nice, juicy polyp with your electric cautery snare, Mr. Geller, and you’ll tell your pretty young assistant to turn on the current to your electric snare.  And do you know what will happen then, Mr. Geller?  Do you know?”  I had to admit that I did not know.

“No, Mr. Geller, you will not know.  You will not know that flatus contains 2% methane gas, a highly inflammable compound.  You will not know this simple physiological fact, Mr. Geller, because you think it unimportant.  Laughable, even.  You will not appreciate the significance of the fact that the gas within your patient’s colon is highly inflammable.  You will not.  And because you are an idiot, Mr. Geller, do you know what will happen?”  I think I might have been smiling at this point as I admitted that I really did not know.  “Your patient, Mr. Geller, will EXPLODE!  Yes!” he said gleefully, “Your high society, polyp possessing patient will explode in your face!  Pieces of your patient will spray across the endoscopy suite, bits of flesh will spatter the walls.  And then do you know what will happen, Mr. Geller?”  I shook my head.  The dog may have barked at this point, I wouldn’t be surprised.  “Then, Mr. Geller, the poor patient’s widow will sue you for medical malpractice.  And then a jury will pronounce you guilty of being a stupid, ignorant git.  And then your malpractice insurance company will cancel your policy.  You’ll be out of a job, Mr. Geller.  Out on the street, destitute!  That’s what going to happen to you, Mr. Geller, because you don’t respect science!”

“If that does happen, Professor Rockport,” I said, “I’ll still be sucking your precious oxygen.  And I’m pretty sure you won’t be.”