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The Skeptical Convert 8/7/13

August 7, 2013 Robert D. Lafsky, MD 6 Comments

The Curmudgeonly Diatribe

One reaction to the penetration of digital technology into medical practice is a type of editorial I hereby term the “curmudgeonly diatribe.” As the name suggests, it’s written by a senior practitioner who is displeased with something — or maybe everything — about the electronic medical record. The prototype is a JAMA piece  "Cut and Paste" but less clever examples have been appearing intermittently over the years. (My own experimental fiction trying to illustrate rather than just complain received mixed reviews).   

The latest such effort  was noted by Mr. HIStalk a few weeks ago, and it goes over ground much covered before (you can read part of it here). It’s well written enough, and not wrong on many specific factual statements, although I think it takes some cheap shots about distracting minutiae in EMRs that should in my view be minute enough to ignore.

But the main thrust of the article stems from a deep appreciation for a literary style of medical recordkeeping that the author remembers from back in his youth. He ends by making a plea for preservation of the kind of nuance an experienced clinician can bring to a case, as well as some sort of separation of what he sees as “the clinical record” from all of the data that clutter up the screen. 

OK, well whether the author may choose to claim curmudgeon status or not, I do, and I share his appreciation of nuance in medicine, especially in the context of evaluation of difficult diagnostic problems. And it’s true–the process of organizing a structured written report does help to organize and direct your thinking toward better conclusions. 

But it’s been obvious for decades that medical information had to be computerized in some way, and it’s obvious that much of the data in the medical record is granular enough to be collated and organized into database format. We had to have some sort of on-screen product. So here’s this big piece of complex software. And you don’t like things about it. You can imagine something better. OK, design it. 

Oh, but that’s not what you’re good at. The fact is that in medicine we’re mentally focused on discovering existing structures, not on creating new ones. Which is why big change in medicine tends to come from outside the clinical confines of the profession, either from basic scientific discoveries or new technological tools.  

And when we do change our internal structures, it tends to be by a gradual — well, gotta call it evolution — rather than wholesale redesign. The whole idea of laying out a new intellectual environment for ourselves has been problematic, not just because we aren’t trained in it, but at a basic intellectual level. We have to accept what our own methodology has done to us.

So outsiders had to design for us. And there’s a lot we don’t like about what we’ve got  But obviously there’s going to be improvement and redesign going on for the indefinite future, and input from specialty users will be critical.  

So sure, complain, but look ahead. And in the mean time, if you like to write and have language skills, there’s a lot you can do right now to improve things. Text is still critically needed –people will pick out coherent narrative and pay attention to it. Write good text, but get it in the system where people will read it. If that means reorganizing your traditional H&P format, APSO style, do it. 

But pay attention to the advantages the computer brings. You may not like the way it organizes things, but it sure does do it consistently. And what it organizes best is lists. You may not want to use them, but others will, and the experts have to police their accuracy. There are things you know that other people don’t. If you know that generic cardiac arrhythmia problem on the list  is WPW, change it.

But stop kidding yourself about the good old days. Back then any hospital had some talented people whose reports were incisive and informative. And a lot of others who just went through the motions. It’s just the same now. But at least now I can read what they are or aren’t saying. 

You can still be a curmudgeon. But be a useful one. Wow, good name for a column …

Robert D. Lafsky, MD is a gastroenterologist and internist in Lansdowne, VA.

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6 Responses to “The Skeptical Convert 8/7/13”

  1. 1
    Lydon Neumann Says:

    Dr. Lafsky provides a nice retort to second guessing and NIMBY challenges, which are often expressions of frustration vs. constructive alternatives. The short answer is that the status quo is what needs to be addressed. There are natural progressions that both pioneers and reactionaries should consider. First, unlike NHS which tried to solve the problem from the top down with billions of pounds wasted on an abandoned approach, we need to effectively and efficiently liberate the data at the source by capturing it. There are lots of ways to accomplish this initial step, but structuring and retaining the content will permit you to move toward assessing and comparing it, which is impractical in a paper environment. With these foundations in place automation permits providers of all kinds to be empowered. With empowerment and liberated information, we can share or connect it, thereby aiding patient care while serving entire patient populations. So the curmudgeon may have a justifiable cause, but progress delayed and/or the unintended information voids waiting for all the sources of patient truth prevent all the larger healthcare continuum from delivering the highest levels of quality sought and required. Thanks, Doc.

  2. 2
    MIMD Says:

    Dr. Lafsky,

    Your essay is quite curious in tone.

    You wrote:

    > So here’s this big piece of complex software. And you don’t like things about it. You can imagine something better. OK, design it.

    Many physicians (esp. employed), nurses, and other healthcare workers are now forced to use health IT, or face disciplinary sanctions from their employer. I hold such HR documents as a result of my own legal work.

    Many physicians don’t like “things” about the “big piece of complex software” for darn good reasons. Like these: bugs that can kill, mission hostile user interfaces that promote “use error”, and worse.

    “You can imagine something better so design it” is a puzzling statement.

    Being forced upon clinicians, it’s not their responsibility to “design their own.” Rather, if what they are presented with is bad health IT, it’s their responsibility to refuse to use it and for the designers, implementers and policy makers to do better … or take accountability for bad outcomes as a result of use error.

    Bad health IT, by the way, is IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.

    I actually recommend great caution in use of these systems, as I and others have begun supporting plaintiff attorneys in cases of EHR-related medical malpractice and evidence tampering. Sadly, the clinicians are the ones who mostly are accountable for the results of bad health IT, not to mention the injured and dead patients and their families. I am trying to put myself out of that line of work via education about the risks of bad health IT (to both the plaintiff and defendant bar, although the latter’s interest seems tepid) and encouragement of the most aggressive of clinician resistance to its use, but hyperenthusiasts like you make that difficult, I’m sorry to say.

  3. 3
    MIMD Says:

    re: “There are natural progressions that both pioneers and reactionaries should consider”

    Actually, the hyperenthusiasts who ignore the downsides are the real problems. The tension is between clinicians with patient care responsibility and cavalier IT hyperenthusiasts.

    It;s quite natural to be several years into a national rollout and then commission IOM and NIST to study health IT safety and usability, as has been done -

    - On Htrae, that is.

  4. 4
    Mark Says:

    Agree with your comments on the general uselessness of complaining from the sidelines by those not willing to get involved. But I can’t help but disagree on your conclusions about innovation. Some of the towering achievements of the last several centuries in healthcare were made by insiders to the health system, and a number of them are physicians. Without their contributions we would not have most of the drugs or surgical techniques we currently use and would still be bleeding people.

    Where there has been significant barrier to innovation recently it has come in the form of barriers to interoperability. Where systems are not supporting standards based interoperability, there is no ability to have your statement “just design it” be in any way practical. It would seem that in your framework we accept the usability of the systems provided. That’s a tragic waste of the great work that smart people are doing in the best institutions around the country.

    So that’s certainly a curmudgeonly diatribe, and probably not a useful one. But I hope the message is useful. Fix innovation, embrace interoperability and hold your friends and colleagues to a standards based approach that gives us the kind of innovation and flexibility that other industries so long ago achieved. I do not like being the subject of amusement for my neighbors who are executives in financing and advertising.

  5. 5
    Dr. Herzenstube Says:

    Well said.

    I have made exclusive use of EHRs in my clinical practice (3 different ones) over the last 17 years and (eschewing false modesty) will put my clinical notes up against anyone’s as faithful, and readable, representations of my encounters with patients and my clinical thinking.

    I do not think an EHR can force a physician to write a bad note. If you choose to use the documentation toolset of your EHR, that doesn’t exempt you from the responsibility over the end product. If the documentation toolset is wanting (as is the one in the EHR I am using now), then you should type your notes free-hand. It’s still faster to type than to write them by hand, so time shouldn’t be a factor. If it truly is, invest a few hundred bucks in a good headset and speech recognition software and you’ll be fine. But don’t generate bad documentation and then blame the computer!

  6. 6
    Not Tired of Suzy, RN Says:

    I often see daily progress notes that have a phrase “patient continues on antibiotic Unasyn”, that I read days after the antibiotic was discontinued. Call me and my doctors carmudgeons, but the cut and paste functionality should be banned from these devices. That is our creative advice.

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