One More Thing on EMR Flaws, Dangers: Why Patients First?

The Daily Apple™© Volume 2, Number 9
August 29, 2013

Technology Failed Again.  That reminds me to remind you about the need for redundancy, when it comes to HIT stuff.

When thinking about EMR<>EHR<>HIT stuff and designing better HIT systems ... remember this.
Wall street went down on (Thursday, August 22, 2013)

  http://dealbook.nytimes.com/2013/08/22/nasdaq-market-halts-trading/?nl=todaysheadlines&emc=edit_th_20130823&_r=0

but, nothing happened.  A few guys made less money?  There was a delay in trading ... so what?  Who cares?  If I were one of those trader guys, I would have hiked out of the office, grabbed a cup of coffee, walked down to the river, felt the sunshine and watched the water run by.  "Call me when things are back up and running."  But, in my business, I can't do that.

There are few things in life during which time is critical.  In fact, time is usually irrelevant.  But, in the spectrum of life, health, healthcare and death, the natural history of injuries and diseases dictate some of the critical moments in life.  So, chill when you can ... drink the coffee and smell the roses.  And, recognize those things that require immediate attention ... true emergencies.

In other words, there are certain illnesses and injuries during which minutes ... even seconds of delay in proper diagnosis and definitive treatment may result in permanent cell damage, organ damage, loss of limb, or loss of life.  The diagnosis and treatment of these conditions is CRITICAL CARE ... That's my day job.  In this business, there is no excuse or time for "systems down".  In other words, we have to be ready to take care of these sorts of problems 24 x 7 with or without technology.  That is the simple truth.  Veritas!

During Katrina, ALL SYSTEMS WERE DOWN within a few hours and they stayed down for days to weeks.  In the immediate aftermath of Katrina, we had NO RECORDS on many patients, some of whom were critically ill.  Direct care Patient<>Physician<>Provider prevented many disasters in our hands.

Intermittently, every electronic record and system I have used has failed.

Intermittently, every piece of technology I have ever used has failed.

Conclusion:  There is no such thing as failsafe.  But, we can build redundancy into EMR<>EHR<>HIT Systems that will generate smart cards and "hard copy" intermittently, at a frequency to be dictated by the "situation" the patient happens to be in at the moment.  If "the patient" is in the hospital, or the Intensive Care Unit, hard copy of the EMR/flow sheet should be printed out at least every 8 - 12 hours. At the push of a button, the "system" should generate a smart card and paper summary for each patient.  In critical situations, attach that summary and smart card with all essential data, at least a problem list, to name tag that hangs on the patient's neck.  That way, the patients and the folks on the front lines with the patients who are responsible for their care will have a little something to help them get some background information.  And, the folks who receive them will also have something to go on.  Add this capacity to the design of any robust EMR<>EHR<>HIT System.  Just my opinion.

And, HIT guys ... don't look at me as if I have two heads when I tell you these things.  Fix it!

Dr. Mike
Michael F. Mascia, MD, MPH

EMR Flaws and Dangers: Patients First, Not the Medical Record

The Daily Apple™© Volume 2, Number 8
August 9, 2013

PGY 41, Day 40

Electronic Medical Records: Flaws and Dangers

ALWAYS GO TO THE PATIENT FIRST

Here are ten reasons why you & every provider should ALWAYS go to the PATIENT FIRST and NEVER go to the record first, or copy and paste from the ELECTRONIC MEDICAL RECORD (EMR)

1. SICK PATIENTS CHANGE FAST: INTERVAL CHANGES IN HISTORY AND PHYSICAL EXAMINATION WILL BE MISSED

You may miss clinical changes that are important to early diagnosis and treatment

2. THE RECORD MAY NOT BE ACCURATE: THERE MAY BE ERRORS AND OMISSIONS

Previous examiners may have skipped parts of the history or physical examination

3. SOMETHING MIGHT HAVE BEEN MISSED IN THE LAST EVALUATION

The natural history of most diseases includes a preclinical, or undetectable phase, which may or may not be symptomatic. Frequent evaluation of the patient, including repeat history and physical examination is an essential part of early definitive diagnosis and treatment.

4. THE RECORD MAY BE INCOMPLETE

5. YOU MAY BE LOOKING AT THE WRONG RECORD

6. SOMEONE MAY HAVE MADE AN ERRONEOUS ENTRY INTO THE RECORD

7. DISEASES EMERGE OVER TIME: EARLY & DEFINITIVE DIAGNOSIS AND PRECISION TREATMENT MAKES A DIFFERENCE

This is intuitively obvious and proven empirically for several diseases. Follow the data and use your intuition for now. Target: Early Definitive Diagnosis and Precision Treatment

8. THE MORE PEOPLE WHO EVALUATE THE PATIENT (NOT THE RECORD) THE MORE ACCURATE WILL BE THE EVALUATION

Intuitively obvious. Do you need proof? Talk with me and we will do some research to prove it.

9. THE MORE OFTEN THE PATIENT IS EVALUATED, THE MORE ACCURATE WILL BE THE EVALUATION

As in number 8 above.

10. COPY AND PASTE IS CHEATING, PLAGIARISM & FRAUD

Yes, and it is a bad idea to cheat patients and cut corners on patient care. This is a problem that results in suboptimal outcome. Do you need proof for this?

SUMMARY AND CONCLUSION

Sick Patients, especially when critically ill, can change rapidly. The natural history of each disease, the way in which each disease presents in a particular patient (host), the preclinical phase and the clinical presentation can vary dramatically from one -DISEASE<>PATIENT (host)- to another. This is the reason for frequent and repetitive patient evaluations. In other words, frequent evaluation by multiple providers increases the accuracy and speed of diagnosis and proper treatment, and this is the right thing to do for all patients at all times. It is NEVER OK to cut corners on patient care.

Electronic Medical Records make it very easy to cut corners, to go to the record first, to copy and paste, to take the note that someone else wrote, to copy it and paste it in as if it were your note. In other words, if you don't write the note based upon your history and physical examination ... if your note is not based upon your evaluation of the patient, you are cheating the patient. Don't do it! ALWAYS go to the PATIENT FIRST. To copy in paste is plagiarism, fraud and cheating the patient out of best possible care.

At best, the Medical Record, Electronic or otherwise, is an imperfect reflection of the patient. In other words, even if it is a "perfect" record, or a "perfect" EMR, it is limited by our knowledge of the patient at one point in time. Over centuries, the medical profession has learned a few things that are easily undone by the EMR. You in the EMR business? HIT people? Do NOT ENABLE COPY AND PASTE for history and physical examinations and interval notes.

Each note, history and physical examination should stand alone at a point in the timeline of each patient's life. It is a reflection of each physician<>patient relationship at one point in time. Each is personal and unique ... not to be undone by technology or methodology. And, if done properly, Doctor, your notes will be accurate and lead to better and best outcomes in patient care.

Salute! Amore e buona fortuna. It is all about Love. There is not enough money in the world to make this right.

Join us.  Help Build Better Health and Healthcare through Patient<>Physician Cooperation and Cooperatives @ www.ihealsolutions.com  and our non profit @ www.VeritasHC.org

Dr. Mike

Michael F. Mascia, MD, MPH

This is Personal: The Patient-Physician Relationship

PGY 40, Day 344

"This is Personal: The Patient-Physician Relationship", was written by me and it is, simply, my opinion ... perhaps not? 

I sent it to the Veritas Health Care Working Group on June 8, 2013, and it is posted here so anyone who wishes can read and respond.

TO: Veritas Health Care Working Group (VeritasHC.org)
From: MFM
Regarding: This is personal.

Please respond, be critical and tell us about your personal experiences inside "The Business of Medicine."

Thanks,
MFM
This is Personal: The Patient-Physician Relationship
by
Michael F. Mascia, MD, MPH

Why would I put my life in the hands of someone whom I do not trust?  Why would I put my life in the hands of a Physician who is forced to cut corners on care by hospitals and third parties?  Don't do it!  Elective? Put it off.

I work with all the casualties ... I see the ones that come in off the street and I see those that come from the hospital.  What I see is very disturbing.  It is NOT RIGHT and it has to change.  Help us change it.

Picture this: Imagine you are the patient. You come in for elective surgery first thing in the morning.  Your attending anesthesiologist is with you and there are no records to reflect preoperative clearance.  He has 2 other patients ... 2 other cases to start at 7:15 ,,, the same time your case is scheduled to start.  So he is hustling and he has little help.  Your "anesthesia provider" is an inexperienced resident and the attending anesthesiologist has to teach and verify that everything is done properly to minimize the risk to you. And, the anesthesiologist knows this: standards of care dictate that certain information in addition to his history and physical is required to meet BEST PRACTICE STANDARDS.  These STANDARDS also dictate certain preconditions.  But the anesthesiologist does not have that information ... he requests it.  And ... your blood sugar is a little high ... got to bring it down before we go.  And, we have to make sure we have blood available in case of a disaster.  Big surgery = high risk.

BUT, the factory pushes ... all eyes are on this anesthesiologist ... because he is SLOWING THE LINE DOWN.  Yes, that's right, you are being treated like a hunk of meat on a production line.  That's the way you are seen ... A HUNK OF MEAT BEING PROCESSED ... and, God forbid the Anesthesiologist hold up the line, or STOP THE LINE for the sake of good OUTCOME.  Yes, I have been that anesthesiologist and when I work that line, I put myself in the position of the patient ... that is the only way to guarantee BEST PRACTICES.  But, if I stop the line, I become "THE PROBLEM" and all the pressure is on me, and they just want to REPLACE ME with someone who does not know any better.  They call this "Production Pressure" and it is an evil reflection of Profit over People that is rampant throughout US hospitals ... every day ... across the country.

Yes, the Business of Medicine in conjunction with third party payers has violated our trust.  By undermining the Physician, they undermine the Patient-Physician Relationship and "Best Care" in favor of Profit.  We all feel it and some of us know it.  That's why everyone I ask ... Patient, Physician, Nurse, other provider ... is disgusted by it.  And, that's why Veritas Health Care is working to create alternatives to Business as usual in Health and Healthcare.

It is the allegiance between patient and physician, and yes, the strength of the bond between Patient and Physician that dictates the healing power of the Patient-Physician relationship.  Over the last 30 years, third parties have systematically disrupted this bond, in favor of "medicine by the numbers", corporate doctoring, third party power and profits over patients.  There is increasing awareness of the problems

Veritas Health Care recognizes the values of the physician-patient relationship and is dedicated to supporting others who value it.

This is personal.

Please join us.

We have tools that will help you Take The Best Care™© of yourself and we will teach you how become an equal member of the healthcare team ... how to help your doctor Take The Best Care™© of you, if and when that becomes necessary.

Dr. Mike