Wednesday, April 21, 2010

The Dark Side of EHRs

Sir Cyril Chantler noted, "medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous." His quote was from a Lancet article in 1999 - much before EMRs were being used regularly. I wonder what he would say now!

I blogged back in February about the FDA's consideration of regulating EMRs... and a series of recent stories have come out reminding us of the unintended consequences of using information technology in healthcare… the truth being that problems occur due to a combination of issues, including;
Implementation problems, such as forcing through awkward workflows.
Technical problems, such as failed integration, slow speeds, system outages and true errors in the system design (e.g. 1 + 1 = 3).
Usability problems, such as difficult to read screens, which can affect speed and judgment. Something I've been commenting on a lot in the past year, as in blogs of April, 2009 and August, 2009.

Here are two interesting stories from the Huffington Post Investigative Fund (a new nonpartisan nonprofit dedicated to in-depth reporting):
As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge : A device that is central in the shift toward electronic medical records systems has been linked to instances of death or injury, according to an Investigative Fund review of Food and Drug Administration data.

Amid Digital Records Surge, a Lack of Policing by the FDA: As federal officials encourage the rapid expansion of electronic medical records to help doctors improve care and cut costs, they lack a reliable and systematic method for tracking the safety of these products, agency data and audits show.

Finally, my friend Dale Sanders, a well-known healthcare CIO, wrote an excellent blog bringing the personal touch and common sense thoughts to this topic of Patient Safety and EHRs.
I love this quote: Remember when safety belts in automobiles first became popular? They were simple lap belts, no shoulder strap. Did they aid passenger safety? Yes, in some ways… but they also introduced the danger of a whole new range of injuries, such as lumbar separation and paralysis, which hadn’t previously existed. It wasn’t until we added shoulder straps and the three point anchor to seat belts in cars that the evidence of benefit to passenger safety became clear and without question. We need pause now and add shoulder straps to EHRs.

If you are interested in searching the FDA's database for HIT problems, or submit one of your own, you can do so at MAUDE (Manufacturer and User Facility Device Experience)

With all that said, this should not stop the forward march of EMRs and HIT from helping us improve the quality and efficiency of healthcare... but it should certainly remind us that we are FAR from our ultimate destination and we all (vendors and users) have to figure out how to build, implement and use these systems better and better...

Other stories and articles
NY Times article (April, 2010) on how EMRs in the exam room can provide so much info that it pushes a doctor into “cognitive overload”

The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry (JAMIA, 2007)

Overdependence on Technology: An Unintended Adverse Consequence of Computerized Provider Order Entry (AMIA Conference, 2007)

The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration (Intl J of Med Informatics, 2009)

Rush to Electronic Health Records Could Increase Liability Risk
(Insurance Journal, June, 2010) which references this paper:
E-Health Hazards: Provider Liability and Electronic Health Record Systems

Nov, 2011: has been created in collaboration with medical professional insurance carriers and adverse event reporting and government experts to improve EHR and patient safety and help to reduce professional liability. EHR event reports will be provided to participating EHR vendors and kept confidential by PDR Secure™.  Information from the PDR Secure PSO may be used by medical professional insurance carriers and the FDA to better understand EHR events and to develop education materials that will increase patient safety and benefit physicians and other clinicians in their use of EHR technology.

Tuesday, April 13, 2010

Stats and Stories

With the recent passage of the Healthcare Reform bill (meaning more patients will be looking for PCPs), along with HITECH getting closer to reality... we will be seeing more and more stories such as these:

Physician Shortage
WSJ Article (April, 2010)
The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors. Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges. That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000. The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient. The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007. A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients....

No surprise, a big part of this is due to:
Gap between PCPs and specialist compensation
MGMA Study (April, 2010)
Annual compensation for primary care and specialty care groups in academic practice slowed between 2008 and 2009, increasing only 2.93 percent for primary care physicians and 2.43 percent for specialists, according to the MGMA Academic Practice Compensation and Production Survey for Faculty and Management: 2010 Report Based on 2009 Data. Primary care physicians reported compensation of $158,218, while specialty care physicians reported compensation of $238,587, a difference of $80,369. From 1999 to 2009, compensation in academic practices continued to trail that in private practices.

Problems with the US Healthcare System, and Kaiser as a shining beacon.
This short story in the Economist (April, 2010) aptly (and somewhat pessimistically describes) how; for the most part, the American health system is dominated by cream-skimming health insurers and the myriad “fee for service” providers they do business with, which drive up costs by charging high prices for piece work. Whereas Kaiser is able to balance quality with cost AND patient satisfaction because it "aligns incentives both to promote parsimony and to improve the quality, rather than merely the quantity, of the care it gives." Thanks for Dr. Ted Eyten for finding and posting this in his blog first.

And we have to deal with this...

The Invisible (Uncompensated) Burden of PCPs
A NYT story (April, 2010) highlighted a NEJM article on this topic and points out the need to change how PCPs are paid — particularly as the new health care law promises to add millions more patients to the system.
The NEJM article (April, 2010) details the uncompensated work burden on PCPs, including about 100 extra tasks a day - including telephone calls and emails for various questions and refills, labs and other studies which need interpretation and communication to patients, as wells as forms and other paperwork for things like school paperwork and medication approval.

The Challenge of Multiple Comorbidity for the US Health Care System
Article in JAMA (April, 2010)
The aging of the US population, combined with improvements in modern medicine, has created a new challenge: approximately 75 million people in the United States have multiple (2 or more) concurrent chronic conditions, defined as "conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living". Is the 21st-century US health care system prepared to deal with the consequences of successfully treating patients who have conditions, often multiple, that they would not have survived in the early 20th century? Current indications suggest that it is not. As the number of chronic conditions affecting an individual increases, so do the following outcomes: unnecessary hospitalizations; adverse drug events; duplicative tests; conflicting medical advice; and, most important, poor functional status and death. Approximately 65% of total health care spending is directed at the approximately 25% of US population who have multiple chronic conditions.

A wider look at health in the US
CDC Report on Health in the United States, 2009
- Use of MRI, CT and PET imaging has soared in the past decade
- Rates of many procedures have increased dramatically: knee replacements (up 70%), Angioplasties with stents (75% of all PTCA in 2006), Fertility treatments (especially in females > 40), Outpatient endoscopies (rose 90%).
- Prescription med use is also up: Diabetes drugs (up 50% in patients over 45), Statin (up 10-fold in past decade), Percent of people on at least 1 drug (increased from 38 to 47%), those taking three or more drugs (increased from 11% to 21%).
- Life expectancy has improved a little. Overall mortality from Cancer, Stroke and Heart disease has declined. Deaths from Respiratory illness and accidents are stable.
- Leading causes of death (by age): 1-44 (accidents), 45-64 (cancer), over 65 (heart disease)
- Chronic conditions: steady at 10% of people reporting chronic conditions limit their activity - most likely arthritis and other musculoskeletal issues. Second leading cause was Mental illness (age 18-44) or heart/circulatory disorders (over 45) - with mental illness a third in that age group.

Meanwhile, with respect to HIT...
Health IT: The Road to 'Meaningful Use'
Health Affairs (April, 2010)
A series of articles that reviews many of the pros/cons of trying to adopt HIT/EMRs to meet our growing needs for quality and care coordination. On one hand, there are definite theoretical advantages to using HIT, and there is a push to do something NOW rather than wait forever for "perfect systems". On the other hand, these systems are still immature and success is often more about workflow re-engineering, executive support, and process and culture change rather than on any specific technology... thus implying that attempting to rapidly adopt IT tools may result in more problems and implementation failures since the other non-IT support needs are so high.

Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?
Center for Studying Health System Change (HSC) study (April, 2010)
Commercial electronic medical records (EMRs) both help and hinder physician interpersonal communication—real-time, face-to-face or phone conversations—with patients and other clinicians... EMRs assist real-time communication with patients during office visits, primarily through immediate access to patient information, allowing clinicians to talk with patients rather than search for information from paper records. For some clinicians, however, aspects of EMRs pose a distraction during a visit . Moreover, some indicated that clinicians may rely on EMRs for information gathering and transfer at the expense of real-time communication with patients and other clinicians. Given time pressures already present in many physician practices, EMR and office-workflow modifications could help ensure that EMRs advance care without compromising interpersonal communication. In particular, policies promoting EMR adoption should consider incorporating communication-skills training for medical trainees and clinicians using EMRs.

Re-Inventing Primary Care
From Health Affairs (May, 2010): "The nation’s primary care system is broken, and fixing it is an urgent priority—all the more so because of the enactment of national health reform." The May 2010 issue of Health Affairs examines what it will take to reinvent primary care in the United States. Operational, payment, regulatory, legal, and educational reforms will be necessary to improve care and achieve savings —and to prepare for the influx of millions of Americans who will be insured for the first time as of 2014.