Salaried doctors, on average, generate fewer RVUs than productivity based doctors. The question of whether that increased productivity leads to better care is endlessly debated by the wonks in the chocolate factory. Some folks believe that all physicians should be salaried to minimize economic incentives in health care. Again, that comes with benefits and risks to patients and unintended consequences that are under appreciated.
In some cases, providers noted that computer systems hid some of the information; if only three comments could be viewed per screen, they had to click to get to another screen, requiring them to search for information that might demand immediate attention.The study also found that there were fewer visual cues with the computational system. Some providers noted that they used to be able to get a sense of the status of the emergency department just by walking through the room and visually checking the manual whiteboard. “Without that public display, providers have to sit down at the computer and check it, which can add time or reduce awareness,” said a principal investigator.These are potentially disastrous consequences in an ED environment where patients can be highly unstable and serious events transpire rapidly and irreversibly. An investigator in the study observed that "the results provide an important case study of what can happen when new technologies are developed without sufficient understanding by designers of the nature of the work in which they will be used."This last observation raises a more fundamental question: why does such an axiomatic, common-sense statement, especially in a domain as complex as medicine, need to even appear in print?
Patient care information systems like CPOE ... can create unintended or "silent" errors, according to a separate study conducted by the same author in the Netherlands and Australia."Many information systems simply don't reflect the health care professional's hectic work environment with its all too frequent interruptions from phone calls, pages, colleagues and patients. Instead these are designed for people who work in calm and solitary environments. This design disconnect is the source of both types of silent errors …Some patient care information systems require data entry that is so elaborate that time spent recording patient data is significantly greater than it was with its paper predecessors," the authors wrote. "What is worse, on several occasions during our studies, overly structured data entry led to a loss of cognitive focus by the clinician."
“The problems are multiple—the presentation of information is often confusing or invisible, the pull-down menus don’t always make sense,” says Ross Koppel, PhD, who serves on the faculty of the University of Pennsylvania and has studied and written about CPOE extensively. “The alerts that come are almost always overwritten. They’re written by the legal team who don’t want to get sued for anything, so they warn of every drug interaction...”Physicians who suffer “alert fatigue” sometimes overlook something, or the alerts miss potential problems they should have caught. The CPOE interfaces look like “the state of art, circa 1992,” in part because they were developed on an accounting software platform and their development hasn’t yet achieved that of clinical systems, Koppel says.The user interfaces create a “hostile user environment” and are often difficult to read and easy to populate with misinformation, says Scot Silverstein MD, adjunct professor at Drexel University’s College of Information Science and Technology and a healthcare journalist. The confusing user interfaces “actually promote user error,” he says. “Some of these interfaces are guaranteed to cause user confusion and create mistakes—not just CPOE but other (IT) systems, as well...”[CPOE vendor contracts require physicians to] sign non-disclosure agreements prohibiting them from publicly discussing problems with the software. Physicians can tell a colleague about a problem they have been having with CPOE, but contractually they cannot publicly present that information at conferences or bring it up in online discussion groups...
HEALTH CARE INFORMATION TECHNOLOGY (HIT) vendors enjoy a contractual and legal structure that renders them virtually liability free—“hold harmless” is the term of art—even when their proprietary products may be implicated in adverse events involving patients. This contractual and legal device shifts liability and remedial burdens to physicians, nurses, hospitals, and clinics, even when these HIT users are strictly following vendor instructions. Vendors avoid liability by relying on the legal doctrine known as “learned intermediaries” and on warranties prohibiting claims against their own products’ fitness. According to this doctrine and legal language, HIT vendors are not responsible for errors their systems introduce in patient treatment, because physicians, nurses, pharmacists, and health care technicians should be able to identify—and correct—any errors generated by software faults...Vendors retain company confidential knowledge about designs, faults, software operations, and glitches. Their counsel have crafted contractual terms that absolve them of liability and other punitive strictures, while compelling users’ nondisclosure of their systems’ problematic, even disastrous, software faults...
Leapfrog’s Binder says hospitals “tend to be prehistoric in their thinking” when it comes to healthcare IT, and their vendors have not put interoperability in the forefront of product design. Other industries embrace technology and allow it to work across national and international systems, but some CPOE applications can only talk to themselves......scholars say the “hold no harm” clause should be removed, a move that would quickly improve the software, and the government could prohibit vendors from requiring physicians to sign confidentiality oaths. Providers should be able to share best practices, problems, and data with others using the same software across the country, not just with colleagues down the hall.
A week after reporting that use of electronic health records lowered the cost of care for its customers between 17 and 33 percent, Blue Cross Blue Shield of Rhode Island has backtracked on those claims. In an email sent to FierceEMR, BCBSRI says that while the program significantly improved healthcare quality, its cost data had not been risk adjusted and did not include costs related to infrastructure spending. "At this time we are unable to accurately ascertain the cost implications of the pilot and are retracting the news release..."
EHR contracts contain an increasing array of complicating structures and dense terms that offer fewer and fewer commitments to your practice. The problematic terms include:Broad disclaimers further distance EHR vendors from any responsibility or liability that may result from the use of their products regardless of the cause:Many contracts offer no warranties and sell the products “as is.” Thereby, they have no obligation to fix problems or maintain product relevancy. For example, a disclaimer that the product is offered with no representation of fitness for any specific purpose provides little to compel a vendor to address an issue or problem.Many contracts include practice indemnification of the software vendor for a variety of issues. For example, some contracts do not warrant the clinical content or the ability of the software to record information, but pass risk of any problems to the practice through broad indemnity clauses. On a similar note, some business associate agreements have the practice indemnifying the business associate for inappropriate disclosures committed by the business associate.A number of EHR vendors will not commit to support HIPAA Security or Privacy standards or Certified EHR status.
...just as the country’s physicians are shifting to digital records in large numbers, so, too, is the amount of confidential medical data being breached, according to a second story by Goedert.Some experts, in fact, say medical data is no safer now than a year ago, Goedert writes. And a recent data breach at Sutter Health Foundation in California put at risk the medical data of 4 million patients.
When the ED nurse brought up my mother's allergies, they were repeated over and over and over on the ED screen, in a long recurrent list dozens of lines long, as if they'd been cut-and-pasted multiple times at each visit.
Vitamin K (Aquamephyton) reverses the blood-thinning effects of coumadin. It acts most quickly and is most effective when administered intravenously.That is, if the computer, now mediating and regulating an increasing amount of healthcare operations, allows the physician to order it that way.It takes perhaps 3 seconds to write an order such as "aquamephyton 10 mg IV STAT", and a minute or less for the order to be called down to pharmacy by a clerk.The computer version of the same task worked a bit differently for a very ill patient:A hospital resident physician, when told to order IV Aquamephyton for urgent administration to this over-anticoagulated patient with atrial fibrillation who had already suffered a subdural hematoma, could only order it subcutaneously due to computer restrictions.A half-hour of investigation, IT experimentation and phone calls needed to be made to the attending physician and the pharmacy to override that limitation, while the patient lay at critically high risk for another life threatening bleed......the drug and dosing options are listed (but spelled wrong in 2 ways - "aquaAMEPHYTOIN" - which is why "aquam" failed to match anything)...
Despite extensive nursing informatics support (approx. 7000 hrs per month for the first six months after implementation), our error rate went from approx. 176 medication errors per day one month after implementation to approx. 100 medication errors per day currently. It has been stable at this level for at least the past 3 months. Many of these errors involve high risk medications (e.g., heparin, morphine). In order to understand the etiology of the errors, i need to explain how cerner processes CPOE orders.With Cerner, orders are grouped into plans (powerplans). These plans can include sub-plans (phases) and sub-sub-plans (sub phases). A typical orders display screen appears as follows: (b)(4). Under the plans is an order tab which displays other orders.This design allows two distinct sources of error.First, there is no consistent way to view orders for medications. A medication order can display either in a plan, sub-plan, or under the orders tab...This facilitates duplication of both medication and non-medication orders (there is a medication checker which is so poorly designed and does little to aid the pharmacists in detecting duplicate medications).Second and more dangerous, high risk intravenous medications can be run either inside or outside of the plan...
In 2008, Smith and his team worked to get hospital board members and executives to champion the cause, which limited the amount of pushback from hospital CEOs and physicians...
Also important to the speed and success of the project: keeping IT team members from tweaking systems as they were being rolled out.
"That was probably the most difficult, the fact that we needed to stay on task for 27 months, to keep heads down," Smith said. "It would have been nice to have been able to stop along the way, catch our breath and do some optimization of the system."
The typical daytime (and rotating) hospitalist encounters 17 patients per shift, and has nearly four admissions and four discharges. Roughly three-fourths are existing patient encounters while the remaining one-in-four are new patients.
ARCHIVED QUESTIONS
Q:How many shifts do adult hospitalists work in an average month?
A:15. Average shifts per month for all respondents actually have dipped since 2009, when the average was 16.28.
Q:How much did adult hospitalist income rise from 2010 to 2011?
A:6%. Average income for adult hospitalist rose last year from $214,700 to $227,300
CONSIDER IT A DILEMMA of the computerization of health care. While electronic medical records need physician input via computerized provider-order entry (CPOE), doctors are having a tough time figuring out how to navigate systems that are being rushed to market.
A case in point: A recent study revealed that introducing a CPOE system with clinical decision-support actually increased the number of duplicate medication orders. The irony is that CPOE is supposed to prevent that exact problem.
The study, which was published online in July by the Journal of the American Medical Informatics Association, found that after CPOE was implemented, duplicate medication orders jumped from 2.6% of all orders to 8.1%. The study looked at drug orders in two ICUs (adult and cardiac) at a 400-bed community teaching hospital...
What finding was most disturbing?
Many duplicate orders were placed within an hour of each other, sometimes by the same provider, sometimes by different providers.
Why didn't the warning systems work?
There was a problem with how the algorithms were designed. Duplicate order checking is based on identifying similar medications, which includes both the medication name and the route of administration. If I said, "Replace potassium," but one person ordered it by IV and one ordered it orally, the system doesn't issue a duplicate med alert because the routes of administration are not the same. That needs to be changed.Read the rest...
The alert picked up three different kinds of duplicates: the same order, the same medication and the same drug class. Many duplicate alerts for drugs in the same class are false positives because we use a lot of meds in the same therapeutic class. Plus, we found that the content of the alerts that popped up was very complex.
