Posts Tagged ‘EMR’

“I’m here to say ‘Yes, they can,’ which is different from ‘Yes, they always do,’” says James Moore, MD, President-Elect of the California Society of Anesthesiologists (CSA).

To the contrary, enthusiasm for electronic medical records (EHRs) is part of a “syndrome of inappropriate overconfidence in computing,” argues Christine Doyle, MD, the CSA’s Speaker of the House.

The two physician anesthesiologists (and self-identified “computer geeks”) squared off in a point-counterpoint debate in New Orleans as part of the American Society of Anesthesiologists (ASA) annual meeting, with Dr. Moore defending the benefits of EHRs and Dr. Doyle arguing against them. Dr. Doyle chairs the ASA’s Committee on Electronic Media and Information Technology, while Dr. Moore leads the implementation of the anesthesia information management system (AIMS) at UCLA.

Legibility, accuracy, quality

Dr. Moore defined safety in anesthesia care as “minimizing patient injury resulting from or occurring during anesthesia, and keeping surgeons from harming patients any more than they have to.” He said that computerization contributes to safe anesthesia care by improving legibility, offering clinical decision support with readily available reference information, and providing alerts and reminders.

Computer tracking of the anesthetized patient’s vital signs is more accurate, Dr. Moore said. It prevents the “normalization” of blood pressure that tends to appear on the paper record. Quality reports are easier to generate and outcomes are easier to measure with EHRs in place, he noted. “Postop troponin levels and acute kidney injury are easy to track.”

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The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.” Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license.”

What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.

So I would like to know, please, when I’ll get to practice at the top of my license?

As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time. Yet I spend a lot of time performing tasks that could be done by someone with far less training.

Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.

I arrived in the operating room at 6:45 a.m., which many non-medical people wouldn’t consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.

First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart. This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.

(Just for fun, I sent an email one day to the head of environmental services at my hospital, asking if the cleaning crew could attach a new suction canister to the anesthesia machine after they remove the dirty one from the previous case. The answer was no. His reasoning was that this would delay the workflow of the cleaning crew.)

Then I checked the circuit on the anesthesia machine, assembled syringes and needles, and drew up medications for the case. To each syringe, I attached a stick-on label with the name of the medication, and wrote by hand on each label the date, the time, and my initials. These tasks, as you might guess, don’t require an MD degree either. A pharmacy can issue pre-filled syringes, and clever machines can generate labels with automatic date and time stamps.

It was now 7 a.m., and I moved on to the preoperative area to meet my first patient. I introduced myself, and started to interview her. Then I noticed that no one had started her IV yet. I asked the patient’s nurse if he would set up the IV fluid, which had already been ordered via the electronic medical record. “If I have time,” he replied.

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We’ve run amok with wearing gloves in the hospital.  And by “we” I mean every healthcare worker in sight.  I see people putting on gloves before they’ll give a patient a clean warm blanket.  This is not only ridiculous, it’s actually harmful.  Here’s why.

We learned the hard way in the 1980s, during the early days of the AIDS epidemic, that the HIV virus and other potentially lethal microorganisms are carried in blood and body fluids. The Centers for Disease Control and the World Health Organization developed the concept of “universal precautions”, which applies during all patient-care activities that may involve exposure to blood, body fluids, mucous membranes and non-intact skin.  Observing “universal precautions” means that you always wear gloves in those situations because you may not know ahead of time if a patient carries HIV, hepatitis, or any other infectious disease.  You don’t want to get infected yourself, or inadvertently infect another patient.

But when did “universal precautions” come to mean that you have to wear gloves before you touch your patient at all?

The downside of hand hygiene campaigns is that they discourage us from normal human contact with our patients.  If you’re worried that the hand hygiene police will detect a deviation from protocol and report you to your hospital’s Infectious Disease authorities, there’s an easy way to avoid the problem. Steer clear of the patient.  And with the advent of the ubiquitous electronic health record, doctors and nurses are under tremendous time pressure to complete all the required data entry fields and move patients through the system.  When you think about it, not touching the patient saves time that could be more efficiently spent at the computer keyboard.  There’s a win-win situation, you might think.  But is it really?

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Wait. Who’s burned out?

How the Affordable Care Act is worsening physician burnout, and why women physicians may be at even higher risk

To the literal-minded, burning out is the fate of light bulbs and matches.  But whether you read the popular press or medical journals today, you’re likely to find writers who are deeply concerned about “physician burnout”.

What defines “physician burnout”, and who exactly is suffering from it?  Is burnout an actual clinical syndrome, a slang term connoting fatigue and boredom, or a hazy combination of the two?  Which medical specialties have the highest rates of burnout, and are men or women physicians more susceptible?  The more you read, the more you realize how much pop psychology and sloppy language are clouding an important issue.

A perfect example of murky logic comes to us courtesy of Dr. Danielle Ofri, who wrote a recent piece for Time called “The Epidemic of Disillusioned Doctors”.  She claims that young women physicians who work in salaried primary care positions are more “resilient” than other doctors, and less likely to become disillusioned about medicine.

Now disillusionment and burnout aren’t identical concepts.  You can be quite disillusioned about the politics of medicine, and pessimistic about the future of private practice, while you take care of your patients every day with dedication and enthusiasm.

But in Dr. Ofri’s view, disillusionment and burnout are twin states of mind, and they are the harbingers of medical errors, substance abuse and depression.  The doctors she considers least likely to suffer such problems are those in her own demographic subset.  “The newer generation of female, salaried, primary-care doctors have the most optimistic outlook on medicine,” she writes.  “This bodes well for patients.”

Wait a moment.  May we see the data to back up this claim?  The source that Dr. Ofri refers to is a 2012 publication from The Physicians Foundation, a nonprofit organization that surveyed more than 13,000 physicians.  The survey addressed professional satisfaction and morale, among other issues, and reached conclusions rather different from Dr. Ofri’s.

“The majority of female physicians, employed physicians, and primary care physicians, though less pessimistic than their male, practice owner and specialist peers, are nevertheless pessimistic about the medical profession and express low levels of morale,” the report concluded, wryly noting that younger physicians “simply may not have practiced long enough to become disaffected.”

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This column was featured on the Association of American Medical Colleges’ blog “Wing of Zock” on May 7, 2012, and on KevinMD on May 10, 2012.

One morning recently, I found another physician standing morosely at one of the mobile computer terminals we refer to as “cows”—computers on wheels—that are everywhere now in our hospital. I asked what was the matter.  “Oh nothing, really,” she said.  “It’s just that I don’t feel I know the patients as well as I used to.”

I knew exactly what she meant.  Things are different now that we have the EMR—the electronic medical record.  After two months of use, we’ve learned to our sorrow that these records don’t tell us stories that make cognitive sense.  Instead they offer data in endless lists.

Before the written word, people told stories.  In every culture, around hearths and on journeys, they remembered and retold tales of great deeds, romance, and tragedy.  When we were medical students, we learned to present each case on rounds by telling the patient’s story.  The story had well-defined elements:  the current complaint, the background of genetics or misfortune that led up to the present, the investigation that might clinch the diagnosis, and the plan of action.

The best stories almost told themselves.  The business executive fresh from a transatlantic flight presented with shortness of breath; VQ scan revealed a pulmonary embolism.  The young woman with Marfan’s syndrome began exercising one morning and developed severe chest pain radiating to her back; the echo demonstrated aortic dissection.

Now, however, we have lists.

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