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Showing posts with label Blogs. Show all posts
Showing posts with label Blogs. Show all posts

Friday, November 15, 2019

eHealth news, feeds, business and intelligence sources

There is a lot of information about ehealth and health informatics. I am not talking specifically about academic research journals - that is a whole other sort of information. Sometimes it is difficult to sort out information about healthcare in general from information that is specific to ehealth, as both are so intertwined. I have been following ehealth news sources for over a decade. My inner ehealth journalist would feed on these sources for material - as would a blogger.

Here are "some" of the main sources of information that I have been receiving:

1. Blogs
2. Healthcare Technology Newsletters
3. Health Informatics Association Newsletters
4. Twitter and Facebook
5. Google News
6. Journal subscriptions
7. Business Intelligence

Blogs
Healthcare Technology Newsletters

Health Informatics Association Newsletters
Twitter and Facebook
Business Intelligence
Google News
  • Set a search criteria on "Health Informatics" in favourites



Friday, April 4, 2014

Semantic webTag Cloud at Bioethics website http://www.bioethics.net

Friday, January 3, 2014

Research Ethics Board Decision Making Maximers or Satificers

A fellow McMaster eHealth M.Sc. graduate, Yervant Terzian, has an interesting post on his blog "Yervant's Musings: Healthcare Through a Patient's Lens". He sent me an email asking what I thought because I attended the same conference of research ethics board professionals - the Canadian Association of Research Ethics Boards (CAREB). Yervant is now a community member of a research ethics board and I would like to welcome him to my world! I have been a research ethics board administrative professional for coming up to 14 continuous years.

Here is the link to Yervant's post:
http://yterzian.wordpress.com/2013/12/23/are-reb-members-maximizers-or-satisficers-ethics/

The talk given by Dr. Ivor Pritchard was aimed at REB professionals. Dr. Pritchord is well known in US bioethics and research ethics professional organizations (acting director of US Human Health Services Office of Human Research Protections) , but has been invited to speak at Canadian REB conferences before.  I believe that he holds a PhD in Philosophy. His theory revolves around research on decision making aiming to illustrate how REB members make decisions when they review research projects for clearance. I don't believe the basis of the talk was on his own research into this subject though I may be wrong.

Let me first say that I think there needs to be more research on REBs - on all aspects of it. Research by Dr. Will van den Hoonaard on Canadian REBs was very valuable on describing the kinds of REB cultures that exist in Canada, as well as arguing how a biomedical basis formed the basis for the ethics policies - not easily extended to social science and qualitative research. There has been some research by Rachel Zand, current CAREB president, on how to educate, train and retain REB members. My colleague Dr. Brian Detlor and I presented on own research on REB information systems used by Canadian REBs at this very same conference. We have just recently posted the results on our website <here> but this will also be posted to the CAREB website this month I am told.

I agree with Yervant that the Maximizer vs Satisficer notion on REB decision making might not be the best way to describe the behaviour of REB members because it comes from a consumer behaviour model. Members of REBs are mostly volunteers, and some ethics board gurus have argued that unpaid volunteer membership on REBs is the only way to preserve ethical integrity in this work. True though, that REB members need incentives to do the ever increasing work load. True though, that altruism alone ought to be the guiding light for contributing to the integrity of research. True it is, that the behavioural effectiveness of REB members is needed more often than the efficiency of REB systems.

Applying an economic "Rational Choice Theory" to REB metrics is one way to approach an analysis for insight. However, I think the real effectiveness for this line of reasoning is more applicable for the ethics of healthcare resource allocation, which is the subject of extensive bioethical debate. Rational choice, as well as maximizers and satisficers, can be applied there, and the scenarios are very similar. Making decisions for how healthcare resources can be allocated, especially in underdeveloped countries, is heart breaking at the best of times. Should one patient be allowed a million dollar support system for an extremely rare condition when the same money can be allocated to improve the quality of life for thousands of others? Closer to home, why is physiotherapy not covered by Ontario health insurance? Why are dental services not covered? etc.

The scenarios for decision making used in our break out groups at the conference that Dr. Pritchard presented and that Yervant discusses are life and death decision scenarios. Not all REBs review research that involves life or death risks. Mostly it is medical REBs that review clinical trials involving experimental drugs for persons with terminal or chronic illness that need to decide on risks of living or dying. The risks in social science and qualitative or behavioural research are not so overtly black or white or of that nature.

Another way to look at this is that REB members as Maximizers are more likely to engage in "ethics creep" - spending a disproportionate amount of time on the minutiae of a protocol instead of the major issues. On the other hand, it would be good to have Maximizers when there are research proposals that do have major issues. For the 90% of social behavioural research reviewed by social science/qualitiatve/behavioural REBs, being a Satisficer is the way to go, because this 90% will be research that is not greater than minimal risk, or risk experienced by participants in their everyday life. Ethics review can be done on a Satisficers'  "it is good enough" basis, even though it is not desirable to do so for the purposes of maintaining high academic standards of research quality.

Yervant proposes a "Traits" approach to examining how REB Members make decisions in the review of ethics applications. Perhaps that might be interesting, but I am not sure how it would improve the effectiveness of REB review. Would REB administrators start to recruit new members based on certain "traits"?

The book You Are What You Choose by Scott De Marchi and James T. Hamilton introduces the TRAITS model and identifies 6 categories for an individual’s decision-making process: Time, Information, meToo, Altruism, Stickiness, and Risk

Certainly, we don't want REB members who will try to exert their own agendas, biases, etc., or who would otherwise be disruptive at meetings, or totally non-present wrapped in a cocoon of silence.  In fact, REB members are assigned research ethics applications to review based on their disciplinary expertise first of all, and secondly, according to known personal interests or other areas of knowledge that they might possess. A theory of "Expert Systems" might also be applicable here in case REB members are ever replaced with IBM Watson type systems.

Anyway, I could probably write more like this for a while, but the relevance for eHealth is drifting away. Thanks very much Yervant for applying your insights to the work of REBs!









Friday, August 2, 2013

ehealthenabled.ca new blog on Word Press!

Hello

I have imported this blogger site into a new experimental IP address I have named ehealthenabled.ca but am using the site only for some software implementation experiments. I will continue to blog from there while I compare, Word Press, which is awfully good, to blogger.


Wednesday, May 22, 2013

10 mistakes made implementing IT systems in Healthcare

IT systems tend to fail at high rates. Studying EHR systems that users in hospitals hate using is one of the classics in Health Informatics. I found this piece on the Kevin Pho newsletter and thought it was a very good precautionary guide. We should all know better, right?

10 mistakes practices make in implementing information technology

What is the measure of successful technology adoption? Is it never having to hunt for a missing chart? Is it a reduction in specific operating cost line items? Is it about access to clinical information when you need it and where you need it?
Technology implementation has a significant effect on profitability. The Medical Group Management Association Cost Survey Report beginning with 2010 data shows that total medical revenue after operating and nonphysician provider costs per FTE physician actually increased as total IT expense per FTE physician increased. For multispecialty groups, for instance, among groups that invested less than $10,000 per FTE physician in IT revenue was $230,968; it was $313,900 in groups that spent between $10,000 and 20,000.
But simply acquiring technology is not enough; it is essential to implement the technology effectively to achieve those types of results.
Here, then, are the top 10 mistakes practices make in implementing information technology — and how to avoid making them.
10. Selecting a system based primarily on a demonstration session. Better to be thorough than fast in the practice management/EHR selection process.
  • Apply structure to the process.
  • Incorporate your workflow into the vendor’s application by defining a sample patient case in advance.
  • Don’t sign a contract without a reference site visit — no matter how busy the physician claims to be in order to avoid the visit!
9. Going live with your EHR without a lab interface. Viewing lab results via PDF is cumbersome for providers and trending a patient’s labs without a lab interface requires staff to enter test result values as discrete data, which is problematic and too labor intensive to be cost effective.
Identify the lab that provides the most results to your practice and test the interface with that lab prior to a go-live implementation.
8. Waiting to implement the patient portal. Implement the patient portal first, even before you convert your practice management system or go live with your EHR.
  • Save staff data entry time and effort by encouraging patients to self-register.
  • The patient’s past medical, social, and family history can be captured in the portal and “accepted” or imported into the PM/EHR system.
Getting information into the system will also save the patient time by reducing time in the waiting room. Patients are also usually more accurate and comprehensive when using the portal than they are with paper and pen.
7. Accepting the vendor’s “train the trainer” plan. Your trainer must understand the application of the system, not just which screens to go to to perform which function. Your own standards and processes are critical to how to use the new technology in your practice workflow.
6. Allowing physicians access without training. Don’t issue any physician a login/password without completing the required training. Provide test-out options to the physicians that demonstrate adequate system knowledge to prevent the dissatisfaction that will ultimately arise from not having sufficient training.
  • Provide one-on-two sessions specific to nurse/physician workflow.
  • Include procedural training along with the system know-how training. Answer the question “How does this apply to what we do?”
5. Assigning the project to the wrong person. Do not assign responsibilities for implementation based on seniority or loyalty or because you have no other position available for a long-term employee. The clinical application project manager must have some clinical background or understanding. He or she must understand what a provider sees (and grasps) when they open a chart.
Characteristics necessary for successful project management:
  • Commands authority and respect
  • Able to delegate tasks and lead others
  • Creative problem-solver and analytical thinker
  • Has high level of energy and self-direction.
4. Not including nursing in the selection process. Nurses touch the chart more than physicians do. Messaging and nurse workflow are critical to the successful use by physicians (nurses must do more of it so that physicians do less of it).
Nurses can facilitate the implementation or create barriers to the implementation; get them involved to get the best result.
3. Not elevating the EHR project in the organization. The EHR Project Manager/Director should report directly to the CEO/COO and work in conjunction with the physician champion(s). The manager should participate in the EHR governing body to establish standards and policies and procedures.
2. Making the EHR implementation an IT project. The implementation is about clinical operations and workflow changes. It is about improving operations with the use of a new tool. The EHR is no more IT than the front desk reception is. IT supports the infrastructure, just like the telephone infrastructure.
1. Not investing in ongoing optimization. Technology implementation is not a once-and-done project; it is an evolutionary process. Technology changes what is feasible. Technology adoption is iterative. Static templates will not satisfy changing needs of the end-users.
Implement a formal rounding plan to observe users and to prioritize ongoing development, training, and required modifications.
The initial goal of an implementation should be to acquire enough knowledge to get through the day. Users don’t know what they don’t know and need support as their use of the technology becomes routine.
Remember: Optimize your technology adoption and improve your profitability.
Rosemarie Nelson is principal, MGMA Health Care Consulting Group and blogs at Practice Pointers.

Thursday, May 9, 2013

Consumer health information discoveries

I have been finding a lot of consumer health information websites, both local and international - a whole bunch of them - and I think it all started when I went to the announcement yesterday for the CISCO/McMaster University Professorship in Integrated Health Biosystems, as well as a Research Chair in Bioinformatics. This doesn't have a consumer health informatics label on it, but should have a Big Data one and be a separate post. Patients come into it when data from clinical trials will finally not go to waste but will be cross-linked with research databases to be put to use for medical research. If personal health records ever catch on, and patients consent to have data (whether de-identified or not - but probably de-identified) used for research, this would also be a mine of information as the original vision for PHR was to include genomic records, the intent being the development and perfection of personalized medicine.

This made me think of Dr. Danny Sands who teaches Medical Informatics at Harvard and is working for CISCO. He had a presentation at a conference (AHIC) where I was also delivering my first student paper presentation. Anyway, I read Danny's bio at CISCO which lead me to a blog he participates in called e-patients.net. It has interesting links to the Society for Participatory Medicine, and the Journal of same.

Impressed with that find, I came across by happenstance the meforyou.org website - a website that can cure you. For some reason this site reminded me about some research and journal articles I read, on how intercessory prayer doesn't work scientifically speaking.  It is a website inspired by Facebook new media but created by U of San Francisco:

UC San Francisco is the only university exclusively focused on human health. For 150 years, we've tackled the world's most vexing health issues, from diabetes and malaria to AIDS and cancer. We are driven by the idea that when the best minds come together, united by a common cause, great breakthroughs can be achieved. Because we believe it is perhaps the greatest single breakthrough that can be achieved, we have committed ourselves thoroughly to the realization of precision medicine. We began this movement knowing that we could not do it alone, and continue assured that we will do it together. Join us.

And then I found this surprising and local "searchless" health information website - hi - consumerhealthinfo.ca (a URL I wished I could have claimed). You can't not appreciate the layout, and user interface (think old people with no time to read extensively.) I think Dr. Mike Evans  ( Dr. Mike Evans curates the best health information found online. ) contributes to this site which lead me to his blog and website, which is simply brilliant, and this viral video!




And finally after this amazing journey just seemed to be beginning, Dr. Evans recommended the ultimate consumer health informatics website NHS.UK  I had recently read on a Yahoo website the UK's National Health Service was in the top ten biggest employers in the world! Well, a lot of them were busy preparing this website, and I relish reading their entire medical encyclopedia someday.

Thursday, February 7, 2013

Research Ethics Review for EMR Systems?

This article by Wes Fisher found on the KevinMD.com news captured my interest because what I think the author is saying is that we should have Research Ethics Boards (REB) or Institutional Review Boards (IRB in the United States) to review implementations of Electronic Medical Record systems. It is interesting because I am a research ethics professional and I have a graduate degree in eHealth. He compares developing and use of EMRs to human experimentation, and as we know today, no human research experimentation can be done without clearance by an REB or IRB.  He uses quotes from the Belmont Report, which is one of cornerstone research ethics policies, to make comparisons for the need for human participant protection from possible harms from EMRs.  In the United States there is a technology push for EMRs and a lot of money mandated for development of EMRs. This could and probably does lead to the development of systems that are not going to be successful, and possible pose harm for patients. The ethics discussed in the article is also more about economic ethics, or the ethics of pushing a technology in advance of knowing net benefits, user acceptability, user satisfaction.

I have recently been thinking that EMR systems should not only have Privacy by Design principles built into their conception, development, and implementation, but also Evaluation By Design. We know that IT systems are notorious for high failure rates - up to 70% of them. It is no different in Health IT. In Canada, Health Infoway does have a certification system for EMRs, which costs about $100,000 and several companies have obtained that certification. This is not same as having an REB review the system.  As well, Health Canada can define some EMRs as class II Medical Devices, which require a certification. Class I medical devices only display or transport data.  Class II devices manipulate the data for decision support purposes, and thus, act more like humans - prone to making error. This Health IT failure website has great case studies.

From what I have studied, a lot of private companies are developing innovative healthcare applications to help people with chronic conditions. Often these applications are tested with patients without having gone through an REB review, unless the companies are working directly with university or hospital researchers who have requirements for REB review. At minimum, the clinical efficacy of these systems needs to be proven in such things as controlled clinical trials, before governments and businesses decide to spend vast sums for patient healthcare. As Dr. Norm Archer in the McMaster School of Business says, the return on investment (ROI) in Healthcare has to be improvement in quality of life.

I have been doing some research lately on information system success models, such as the DeLone and McLean model. This model for IS success has been well tested and measure in information systems studies, but I don't know how it has been applied to healthcare. I have seen the Technology Acceptance Model (TAM) used, but I am told this model is overused and many journals don't accept articles anymore using it. I am going to look into how the Delone and McLean model is used in Healthcare, because it could be one of the cornerstones for an Evaluation by Design model for EMR systems.  I also want to think more along the lines of this article by Dr. Fisher, and think about how the Canadian policy for research ethics, the Tri-Council Policy Statement, could apply to the review of EMRs.



The ethics of EMR: How unproven technology affects patients


The ethics of EMR: How unproven technology affects patients
The implementation of the electronic medical record (EMR) in American medicine gained a powerful foothold in medical care with the passage of the American Reinvestment and Recovery Act (ARRA) in 2009. With the passage of this act came the promise of improved efficiencies, safety and ultimately reduced cost delivery for health care. Also, some $18 billion dollars in financial incentives were offered to physicians to offset costs to deploy these systems nationwide. To assure adoption, if the systems were not implemented by 2015, doctors and care providers will suffer payment penalties from the government. For physicians who care for Medicare patients, there was no alternative than to deploy these systems.
In 2010 alone, the EMR market was pegged at $15.7 billion dollars, a cost that is ultimately passed to all Americans. In addition, despite all of the changes that health care reform has brought to date, people in some states continue to see their insurance premiums mushroom over 20% in 2013 from the preceding year. Simply put, patients are finding health care anything but “affordable.”
We should acknowledge that there might be cause, ethically, to deploy a technology that truly benefits patients at some cost. After all, you have to break a few eggs to make a good omelet. If interoperability of EMR systems between facilities were commonplace and clinical data were shared with ease while patient privacy was vigorously upheld flawlessly, the cost of these systems might be ethically justified.
But the promise of improved efficiencies to our health care system, improved patient safety and (especially) reduced cost for our health care system remain elusive. More importantly these goals remain unproven. In fact, examples that the opposite is occurring abounds as doctors struggle to enter ever-increasing amounts of information of no relevance to the patient’s presenting problem just to prove they’re using the EMR in a “meaningful” way, health data security breeches continue, data-mining of patient information is occurring not just for patient care, but for marketing purposes, and the direct costs of health care for patients continues to rise, not fall. Proponents of these systems will argue these issues are nothing more than “growing pains” of these novel systems.
So should we step back for a moment and ask ourselves if we are being ethical to patients with the deployment of this technology? Does the ends of presumed cost savings to our national health care system justify the deployment of poorly integrated, difficult-to-use systems? Are patients being subjected to new risks heretofore never considered with the adoption of this technology? Could a tiny programming error occur that negatively impacts not just one patient, but millions? If so, what are the safeguards in place to prevent catastrophic error? Who will be responsible? Who is the oversight body that assures the guiding principles of the Belmont Report (respect for persons, beneficence and justice) with respect to EMR deployment are followed? The Secretary of the Department of Health and Human Services or a more nebulous body like Congress?
If we accept that the benefits of the EMR are at least uncertain to patients in terms of risk and cost, we should demand they be studied before deploying them. The guiding medical ethics tenets would demand nothing less. So, would not such study qualify as human research? After all, we should remember that the United States and other countries have a precedent of human research programs performed by government agencies that were usually highly secretive, and in many cases information about them was not released until many years after the studies had been performed.
From a sentinel paper in 1966 by Henry J. Beecher, MD on Ethics in Research:
I should like to affirm that American medicine is sound, and most progress in it soundly attained. There is, however, a reason for concern in certain areas, and I believe the type of activities to be mentioned will do great harm to medicine unless soon corrected. It will certainly be charged that a mention of these matters does a disservice to medicine, but not one so great, I believe, as a continuation of the practices cited.
Experimentation in man takes place is several areas: in self-experimentation; in patient volunteers and normal subjects; in therapy; and in the different areas of experimentation on a patient not for his benefit but for that, at least in theory, of patients in general.
While Beecher’s paper was addressing ethical research errors in general, his words are oddly prescient for EMR development. Ethical errors, as he pointed out, “are increasing not only in numbers but in variety.” He points to one of the biggest drivers of ethical conflict: money.
Of transcendent importance is the enormous and continuing increasing in available dollars for research, as shown below:
 
Money Available for Research
YearMassachusetts General HospitalNational Institutes of Health
1945$500,000$701,800
19552,222,81636,063,200
19658,384,342436,600,000

These data, rough as they are, illustrate vast opportunities and concomitantly expanded responsibilities.
Taking into account the sound and increasing emphasis of recent years that experimentation in man must precede general application of new procedures in therapy, plus the great sums of money available, there is reason to fear that these requirements and resources may be greater than the supply of responsible investigators.
The need for “responsible investigators” remains significant; funding for all of the National institute of Health in 2011 was $142.5 billion dollars. Annually, EMR companies have received the equivalent of 11% of the entire NIH annual research budget from US citizens without having to prove their safety or value to patients.
Again, from Beecher’s paper:
The ethical approach to experimentation in man has several components; two are more important than others, the first being informed consent. The difficulty of obtaining this is discussed in detail. But it is absolutely essential to strive for it for moral, sociologic, and legal reasons. The statement that consent has been obtained has little meaning unless the subject or his guardian is capable of understanding what is to be undertaken and unless all hazards are clear. If these are not known this, too, shall be stated. In such a situation the subject at least knows that he is to be a participant in an experiment. Secondly, there is the more reliable safeguard provided by the presence of an intelligent, informed, conscientious, compassionate, responsible investigator.
Because EMR deployments are cloaked in intellectual property, non-disclosure and restrictive hospital employment agreements, doctors are often prohibited from voicing specific concerns about an EMR system publicly. In addition, by adopting EMR systems as cornerstones of the American health care system, Congress, the President and the ARRA side-stepped patients’ informed consent regarding the short-comings of these systems, advertising only their desired benefits instead. Furthermore, rather than Congress turning to “conscientious, compassionate, responsible investigators,” they turned to lobbyists when deciding to fund the deployment of unproven EMR systems. As a result, doctors were relegated to becoming nothing more than stewards of data entry subject to new, ever-evolving documentation requirements as these systems evolve for cost-saving benefits and care “efficiencies.”
Patients and doctors alike understand the need for improved efficiencies and value in our era of exploding health care costs. We must strive to find a solution to our health care cost crisis that is transparent, cost-effective and ethical. Without such an effort, our health care system will collapse. Only recently has the Office of the National Coordinator of Health Information Technology recognized the problem and opened their Health IT Patient Safety Action and Surveillance Plan for public comment. This plan asks the EMR companies and interested stakeholders to develop their own methods to assure patient safety and reporting systems – a move that approaches the same ethical standards as equivalent of asking the foxes to watch the henhouse. Nonetheless, we should acknowledge their efforts.
But we should be cautious of EMR systems as we move forward. After all, these clinical systems have not been subjected to the same cost-benefit and ethical scrutiny as other clinical tools we use in health care. The scrutiny of EMRs should be no different than that found with pharmaceutical or medical device research where Institutional Research Board approval and proof of no conflict of interest is demanded. Why should clinical EMR systems be any different?
Given the profit motives and market consolidation occurring amongst the purveyors of these EMR systems and the potential for lethal EMR errors both from software and human interface issues, doctors and patients must especially question the ethics of the movement to deploy untested, novel technology on our patient population under restrictive covenants. As part of informed consent, patients should have full understanding of how and where their clinical data are used, including when it will be used for direct-marketing campaigns, prioritizing care delivery, or for research. Patients should be able to opt out of the use of their clinical data for these or any other purpose if desired, without restricting payment for care. Finally, physician and patient concerns about EMR systems should be allowed to be vetted publicly and without threat of professional or personal reprisal or the withholding of payments for care rendered, especially and particularly if these disclosures are performed in the best interest of patient care.
To do otherwise is unethical for our patients and the public at large.
Wes Fisher is a cardiologist who blogs at Dr. Wes.
Image credit: Shutterstock.com

Saturday, October 27, 2012

A Pioneer of Medical Records

I found this story on a blog by a Doctor who blogs.  The subject of doctors who blog is an interesting one, but probably for another post.  I watched this video and was very impressed. Dr. Weed is right on. How could anyone audit, let alone make sense of that patients' chart?

The rest of the article by Dr. Wachter I will copy here.  It is an excellent article, the jest of which seems to me to be about usability of the EMR and the EMR not getting in the way of the human person who's digital information is being recorded:

Putting the “A” Back in SOAP Notes: Time to Tackle An Epic Problem

A colleague recently sent me a remarkable video – of Professor Lawrence Weed giving Medical Grand Rounds at Emory University in 1971. It’s fun to watch for many reasons: the packed audience composed mostly of white men in white jackets and narrow ties, the grainy black and white images a nostalgic reminder of Life Before High Def.
But the real treat is seeing Weed, then 47 years old, angular and frenetic, a man on a mission. He begins his talk by rifling through a typical medical chart, thick as a phone book. It is filled with garbage, he says disdainfully; “source oriented” rather than “problem oriented.” Weed was promoting his new vision for the medical record – one organized around patients’ clinical problems.
In 1964, in an article in the Irish Journal of Medical Sciences (reprised, rather more famously, in theNew England Journal in 1968), Weed described his new model for patient care records, known as theSOAP note (“Subjective, Objective, Assessment, and Plan”). The idea was to begin with the patient’s history, then to present the objective data (physical examination, and results of labs, radiographs, and other studies), and finally to describe an assessment and plan for each of the patient’s problems. SOAP notes were designed to populate what Weed called the POMR: problem-oriented medical record.
This was revolutionary stuff at the time, and Weed was ready for pushback from doctors who argued that their random jottings were sacred totems of the “art of medicine.” At 51:30 in the video, Weed addresses these objections:
Art… is not a scribble in the middle of the night…. We debase the word art itself when we call what we’ve been doing art… As Stravinsky says, ‘art is nothing more than placing limits and working against them rigorously’ …and if we refuse to place them… you do not have art, you have chaos, and, to a large extent that’s what we’ve had.  
I like Weed’s problem-oriented format – so much so that one of the reasons I’m pleased when my patients leave the ICU (other than the fact that this usually means that they’re getting better) is that my trainees’ oral presentations morph from being organ-system based (“Neuro: sedated, moving all fours, head CT negative for bleed; Cardiac: MAP 75 on 2 mics of Levophed, heart rate 85, lungs clear, 2 over 6 systolic murmur at apex, good systolic function on echo….”) to problem-based (“Problem 1: dyspnea. Patient remains short of breath, O2 sat 92% on 5 liters, lungs clear on exam and chest x-ray negative. Plan is for chest CT to rule out PE…”). When I hear an organ-based presentation, I find myself struggling to translate it into a problem framework, like someone who isn’t quite fluent in a foreign language trying to make sense of a song in that language.
Whatever the method used to divide patients up into manageable chunks, there is always a tension between a reductionist view of a patient’s problems (or organs) and a big-picture view. Just as we are, biochemically, simply the sum of our cells, even atheists know that humans are far more than that. So too are patients more than the sum of their problems.
Note that I’m not being touchy-feely and holistic here, decrying the dehumanizing aspects of modern healthcare. No, I’m saying that even if you are a coot who doesn’t give a damn about what the patient isfeeling, even if you gloss over the social history in a mad dash to the liver function tests, even if you think that “patient-centered care” is mostly an empty slogan, even if you’re the kind of doctor who simply wants to figure out your patient’s problems and deal with them effectively, you must balance the simplicity and practicality of a systematic approach with the need to see patients as more than the sum of their problems.
With paper notes, this tension usually managed to work itself out. Even as we embraced Weed’s problem-oriented approach, there was something about the act of writing things down that made you realize that there was a person attached to the problems, and that each patient needed an über-assessment – a paragraph or two summing up his or her issues. The reason for this was not so much to honor the patient’s humanity (although that’s nice too) as it was to offer a crucial synthesis of what was otherwise a jumble of facts and impressions.
At UCSF Medical Center, we went live with our version of the Epic electronic medical record three months ago. It beats pen and paper, and it beats the EMR system that we traded out (at a cost of a hundred million dollars or so) by a long shot. The implementation went well overall, notwithstanding a few snafus (several thousand missing billing charges, a few patients temporarily unaccounted for, that kind of thing). I’m certain that these glitches can and will be ironed out.
But I’m less confident that we can fix what Epic is doing to our notes, and our brains.
The system, you see, places the problem list at the core of the patient’s clinical world – in a way that goes well beyond what Larry Weed imagined. One really doesn’t “write a note” anymore; rather one charts on each of the patient’s problems, one by one. At the end of a session, the computer magically weaves these fragments into what outwardly appears to be the patient’s progress note. But it’s not really a note, it’s a series of problems (each accompanied by a brief assessment and plan) held together with electronic Steri-Strips. In other words, it takes Weed’s vision of the POMR and hypertrophies it. As with muscle, while some hypertrophy can improve function and be attractive, there comes a point when more hypertrophy becomes constrictive, dysfunctional, even grotesque.
Why did Epic and our UCSF IT gurus structure things this way? The primary virtue is that this charting-by-problem approach allows the patient to be followed longitudinally, since one can track problems such as “hypertension” or “ovarian cancer” over years, seeing how they have been managed and observing the response to therapy. It isn’t a bad conceit, and it probably makes tons of sense when described in a fishbone diagram on an informatics seminar whiteboard.
But the effect I witnessed on patient care and education was less positive. When I was on clinical service in July and read the notes written by our interns and residents, I often had no idea whether the patient was getting better or worse, whether our plan was or was not working, whether we need to rethink our whole approach or stay the course.
In other words, I couldn’t figure out what was going on with the patient.
If Epic was the only thing promoting this kind of reductionist approach, it might be survivable. But it’s not. In the face of duty-hours limits, our trainees are increasingly programmed to operate in a “just the facts, ma’am” mode, to approach patients as a series of problems to be addressed expeditiously and algorithmically. This “if X, then Y” mode of thinking isn’t wrong, per se, but – particularly in the hospital – when unaccompanied by an effort to paint a coherent overall picture, the notes (and accompanying presentations) can become data without information, empty e-calories.
(Note that this problem comes on top of the copy-and-paste phenomenon so cleverly skewered by Hirschtick a few years back in JAMA. While copy-and-paste must be addressed, I’m less worried about it than I am about the impact of the EMR on clinical synthesis and reasoning.)
Larry Weed was acutely aware of another objection to his problem-oriented approach: the concern that each problem would be viewed in a vacuum. In his 1968 article, he wrote:
Fragmentation of single diagnostic entities resulting from listing separately single related findings is not a legitimate complaint against a complete list of problems. If a complete analysis is done on each finding, integration of related ones is an automatic byproduct. Failure to integrate findings into a valid single entity can almost always be traced to incomplete understanding of all the implications of one or all of them.
In the old days, failure to connect the dots between problems 1, 3, and 6 may well have been due to cognitive gaps. But the modern IT system can prevent even smart physicians from performing this essential act of synthesis. The patient with cough, sinus problems, and kidney failure cannot be thought of as the sum of the differential diagnosis of each of these problems. Instead, as Occaminsisted, these problems must be placed in a Venn diagram, accompanied by strenuous attempts to figure out what lives at the intersection. This is damn hard to do when one is electronically charting each problem independently. Monkeys and typewriters come to mind.
Over the past few years, Epic has “won the game” in the competition among IT vendors trying to sell to large teaching hospitals. This is fine – it is a robust system and an impressive company. But something needs to be done to preserve the essential act of clinical synthesis, and soon.
What would I do? I’d build into each Epic note a mandatory field, and call it “Ãœber Assessment” or “The Big Picture.” Mousing over a little icon would reveal the field’s intended purpose:
In this field, please tell the many people who are coming to see your patient – nurses, nutritionists, social workers, consultants, your attending – what the hell is going on. What are the major issues you’re trying to address and the questions you’re struggling to answer? Describe the patient’s trajectory – is he or she getting better or worse? If worse (or not better), what are you doing to figure things out, and when might you rethink the diagnosis or your therapeutic approach and try something new? Please do not use this space to restate the narrow, one-problem-at-a-time-oriented approach you have so competently articulated in other parts of this record. We know that the patient has hypokalemia and that your plan is to replace the potassium. Use this section to be more synthetic, more novelistic, more imaginative, more expansive. Tell a story.
All in all, I am pleased that UCSF went with the Epic system and I remain a fan of electronic health records. And Larry Weed was right: we must have a structure to record what is happening to our patients, and his problem-oriented approach remains the most appealing one. (Ultimately, one wonders whether natural language processing will make such a structure less important, in the same way that I no longer pay much attention to filing documents on my Mac now that its search function is so powerful.)
But the time is now – before our trainees build habits that will be awfully hard to break – to recognize that electronic medical records do more than chronicle our patients’ histories, exams, and labs. They are also cognitive forcing functions, ever-so-subtly modifying our approach and language into something that can either improve our clinical care and teaching, or not. Let’s show these computers who’s boss, and put the “A” back in SOAP.