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Lack Of Information Synthesis: One Of The Most Important Causes Of Medical Errors

As I travel around the country, working in the trenches of various hospitals, I’ve been struck by the number of errors made by physicians and nurses whose administrative burden distracts them from patient care. The clinicians who make the errors are intelligent and competent – and they feel badly when an error is made. However, the volume of tasks required of them in a day (many of which are designed to fulfill an administrative “patient safety” or “quality enhancement” process) makes it impossible for them to complete any task in a comprehensive and thoughtful manner. In the end, administrators’ responses to increased error frequency is to increase error tracking and demand further documentation that leads to less time with patients and more errors overall. It’s a vicious cycle that people aren’t talking about enough.

As I receive patient admissions from various referral hospitals, I rarely find a comprehensive discharge summary or full history and physical exam document that provides an accurate and complete account of the patient’s health status. Most of the documentation is poorly synthesized, scattered throughout reams of EMR-generated duplicative and irrelevant minutiae. Interpreting and sifting through this electronic data adds hours to my work day. Most physicians don’t bother to sift – which is why important information is missed in the mad dash to treat more patients per day than can be done safely and thoroughly.

I have personally witnessed many critical misdiagnoses caused by sloppy and rushed medical evaluations. I have had to transfer patients back to their originating surgical hospitals (at some of America’s top academic centers) for further work up and treatment, and have uncovered everything from cancer to brain disorders to medication errors for patients who had been evaluated and treated by many other specialists before me. No one seems to have the time to take a long hard look at these patients, and so they end up undergoing knee-jerk treatments for partially thought through diagnoses. The quality of medical care in which I’ve been engaged (over the past 20 years) has taken a dramatic turn for the worse because of volume overload (fueled by diminishing reimbursement) in the setting of excessive administrative and documentation requirements.

To use an analogy – The solution to the healthcare cost crisis is not to increase the speed of the assembly line belt when our physicians and nurses are already dropping items on the floor. First, stop asking them to step away from the belt to do other things. Second, put a cap on belt speed. Third, insure that you have sufficient staff to handle the volume of “product” on the belt, and support them with post-belt packaging and procedures that will prevent back up.

What we require most in healthcare is time to process our thoughts and engage in information synthesis. We must give physicians the time they need to complete a full, comprehensive, evaluation of each patient at regular intervals. We need nurses to be freed from desk clerk and safety documentation activities to actually inspect and manage their patients and alert physicians to new information.

Until hospitals and administrators recognize that more data does not result in better care, and that intelligent information synthesis (which requires clinician time, not computer algorithms) is the foundation of error prevention, I do not foresee a bright future for patients in this manic assembly line of a healthcare system.

Should Patients Have Access To Lab Test Results Before Their Physician Reviews Them?

Six weeks ago I had a skin lesion removed by a plastic surgeon. About 7 days after the biopsy, I received a letter from the pathology lab where the sample had been analyzed under a microscope. I eagerly opened the letter, assuming that it contained test results, but was disappointed to find a bill instead. As a physician, it felt strange to be in a position of having to wait for a colleague to give me results that I was trained to understand for myself. However, I knew that in this case I was wearing my “patient hat” and that I’d need to trust that I’d receive a call if there was an abnormality. I haven’t received a call yet, and I assume that no news is good news. But what if no news is an oversight? Maybe there was a communication breakdown between the path lab and the surgeon (or his office staff) and someone forgot to tell me about a melanoma? Unlikely but possible, right?

Patients experience similar anxiety in regards to lab tests on a constant basis. In a perfect world, they’d receive results at the same time as their doctors, along with a full explanation of what the tests mean. But most of the time there’s a long lag – an awkward period where patients have to wait for a call or make a nuisance of themselves to office staff. Shouldn’t there be a better way?

The New York Times delves into the issue of “the anxiety of waiting for test results,” with some helpful tips for patients in limbo:

As patients wait for test results, anxiety rises as time slips into slow motion. But experts say patients can regain a sense of control.

  • Start before the test itself.
  • Because fear can cloud memory during talks with doctors, take notes. If you can, bring a friend to catch details you may miss.

Some pretest questions:

  • What precisely can this test reveal? What are its limitations?
  • How long should results take, and why? Will the doctor call with results, or should I contact the office?
  • If it’s my responsibility to call, what is the best time, and whom should I ask for?
  • What is the doctor’s advice about getting results online?

Do I think that patients should have access to their results without their physician’s review? While my initial instinct is to say “yes,” I wonder if more anxiety may be caused by results provided without an interpreter. There are so many test results that may appear frightening at first (such as a mammogram with a “finding” – the term, “finding,” may mean that the entire breast was not visualized in the image, or that there was a shadow caused by a fatty layer, or -less commonly – it can also indicate that a suspicious lesion was observed). I’m not arguing that patients can’t understand test results on their own, but medicine has its own brand of jargon and nuances that require experience to interpret.

Consider the slight deviations from the mean on a series of blood tests. They can be perfectly normal within the patient’s personal context, but may simply be listed by the lab as high or low. This can cause unnecessary anxiety for the patient. And what about PAP smear results that are listed as “ASCUS” – atypical squamous cells of undetermined significance? These can occur if the patient merely had recent sexual intercourse, and are not necessarily indicative of cancer at all.

And what about the “ambulance chasing lawyers” out there? Will there be additional frivolous law suits created by lab test results reported direct-to-consumer as abnormal in some way (when they really aren’t, given the full clinical picture) and patients assuming that their physician was negligent by not reporting the abnormality to them sooner? It could happen.

In the end I think that physicians all need to make a concerted effort to forward (with an explanation when necessary) lab test results to patients as quickly as possible. But since doctors are the ones ordering the tests in the first place, they do have a right to see them (before the patient when appropriate) – and an obligation to pass on the information in a timely and fully explained manner. That’s the value of having a physician order a test – their expertise in interpreting the results are part of the package (and cost). When patients order their own tests (and in some cases they can) then they should be first to receive the results.

As for me, I’m going to have to resort to “office staff nuisance” to get my results confirmed… just like any other regular patient. Oh well. 😉

The App Gap: Why Baby Boomers Won’t Use Most Smart Phone Apps

Along with the invention of smart phones, an entire medical mobile application (app) industry has cropped up, promising patients enhanced connectivity, health data collection, and overall care quality at lower costs. Last year the FDA put a damper on the app industry’s quick-profit hopes by announcing that it intends to regulate certain medical apps as medical devices. In other words, if the app is used to connect with a medical device or to turn a smart phone into such a device (whether it can check your blood sugar, blood pressure, heart rhythm, etc. or suggest diagnoses), it must undergo safety and efficacy checks by the FDA before it can be brought to market. That process is likely to inflate app development costs exponentially, thus creating a chilling effect on the industry.

I actually think that FDA oversight is a good thing in this case, since it could protect patients from potentially misleading health information that they might use to make treatment or care decisions. But more importantly, I wonder if a lot of this fuss is moot for the largest, sickest, segment of the U.S. population?

For all the hype about robo-grannies, aging in place technologies, and how high tech solutions will reduce healthcare costs, the reality is that these hopes are unlikely to be achieved with the baby boomer generation. I believe that the generation that follows will be fully wired and interested in maximizing all that mobile health has to offer, but they’re not sick (yet) and they’re also not the proverbial “pig in the python” of today’s healthcare consumption.

I’m not saying that mobile health apps have no role in caring for America’s seniors – their physicians and care teams use tablets and smart phones, their kids do too, and a small percent of seniors may adopt these technologies, but I’m a realist when it comes to massive adoption by boomers themselves. Wireless connectivity, texting, personal digital health records, and asynchronous communication is just not in their DNA. Take away a teenager’s smart phone and he or she is likely to be completely flummoxed by reality. Now give that phone to a baby boomer and the flummoxing will be roughly equivalent, but centered upon the device. The teen can’t live without the constant phone/internet connection, and the senior is overwhelmed by the lack of human interface and unfamiliar menus.

What makes me so sure of my pronouncements? I just spent a month making house calls to almost 70 different Medicare Advantage members in rural parts of this country. And I can tell you that almost none of them used any sort of smart phone app to manage their health. These “odd creatures” actually enjoyed face-to-face human contact, they used their phones almost exclusively to talk to people (not surf the Internet), and they took hand-written notes when it was important for them to remember something. They even had paper calendars that they used to schedule their physician appointments and keep records of their medications and procedures. How “weird” is that?!

When I asked one of the seniors if she’d be interested in using a cell phone to check her blood pressure and have that automatically uploaded to her doctor’s office she replied,

“I’m too old to learn that stuff, dear. I’m lucky if I can find my slippers in the morning.”

The reality is that the average app user isn’t sick, and sick people don’t see a need for apps… yet.  So our challenge is to meet seniors where they are instead of trying to change their habits. House calls are the best way I know of to get a full appreciation for individual quirks, compliance challenges, and health practices. If we are really serious about reducing healthcare costs in our aging population, it may take some low-tech solutions. As un-sexy as that may be, it’s time that we put down the iPhone and practiced some good old-fashioned medicine.

Survey Reveals Just How Stressed Physicians Really Are

The vast majority of U.S. physicians are moderately to severely stressed or burned out on an average day, with moderate to dramatic increases in the past three years, according to a survey.

Almost 87% of all respondents reported being moderately to severely stressed and/or burned out on an average day using a 10-point Likert scale, and 37.7% specifying severe stress and/or burnout.

Almost 63% of respondents said they were more stressed and/or burned out than three years ago, using a 5-point Likert scale, compared with just 37.1% who reported feeling the same level of stress. The largest number of respondents (34.3%) identified themselves as “much more stressed” than they were three years ago.

The survey of physicians conducted by Physician Wellness Services, a company specializing in employee assistance and intervention services, and Cejka Search, a recruitment firm, was conducted across the U.S., and across all specialties, in September 2011. Respondents Read more »

*This blog post was originally published at ACP Hospitalist*

Survey Asks Doctors And Patients If Doctor’s Notes Should Be In The EHR

We are fast entering the era of the electronic health record, when it will be possible to call up our medical records on our computers and mobile devices. Medication lists, lab results, appointment schedules—they’ll all be available with clicks of your mouse or taps on the screen of your smartphone or tablet.

But one question that’s far from settled is whether the electronic health record should include the notes that doctors make about them. A doctor’s notes can be straightforward, such as a reminder that an additional test might be needed. But they can also include somewhat speculative observations and hunches about a patient and his or her medical conditions. The Open Notes project is a research program designed to test the consequences of giving patients access to doctors’ notes. Harvard-affiliated Beth Israel Deaconess Medical Center is one of the test sites.

The Open Notes project is far from finished. But results of a survey of the expectations that doctors and patients have for note sharing are being reported in today’s Annals of Internal Medicine.

I don’t think there are any great surprises here.  More than half of the primary care physicians Read more »

*This blog post was originally published at Harvard Health Blog*

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Latest Book Reviews

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