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The Skeptical Convert 8/7/13

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

The Skeptical Convert 6/7/13

Silos vs. Holes

I hear a lot about data silos on this site, but not about data holes.

We talk about silos in reference to problems with data sharing resulting from differently designed information systems. As a negative metaphor that makes sense (although when you think about it, silos project a certain optimism about plentiful supplies stored away for future use.) But ever since my hospital system adopted a single-vendor comprehensive information system (whose name  shall not be mentioned,) I’ve been thinking about a different problem that needs a different metaphor. 

Consider the following scenario. A specialist — perhaps but not necessarily one at a tertiary facility — performs services on a patient that reveal a serious diagnosis, one clearly not resolved at the time of discharge. In keeping with computer training, said specialist has entered some discrete, mainly compliance-oriented data like med reconciliation in the system.  

But critical information about the diagnosis and interventions are put in traditional dictated reports. These reports are, by traditional standards, excellent– comprehensive and authoritative. And they were probably sent to the referring office-based primary practitioner.

But a few weeks later, the patient shows up in an ER of the same hospital system, with a problem that the patient herself thinks is new and unrelated. But it’s a problem that might lead a fully informed ER doctor, hospitalist, or consultant to conclude otherwise. But they don’t, at least right away. Because what they really need to know is in a hole. 

What do I mean? After all, the information is all there. Somewhere. But the system prominently displays listed summary information that’s supposed to be useful, information that the busy practitioner is inevitably going to rely on for initial decision-making. But nobody edited those lists during the previous hospitalization to include new and vital facts. 

Yes, way down on a list of, um, let’s see, progress notes, nurse notes, resident notes, consultant notes there’s an operative note and, um, what did they find? OK so let’s try to find the pathology report…let’s see….chemistry, micro, imaging, it’s here somewhere. It can be a while before a stranger looking at all this realizes that the patient has something new, and evidently, bad. It certainly doesn’t come across in the headlines the system displays. It’s in a hole. 

It’s funny — years ago I made my local reputation as a diagnostician mainly by asking for all the fat folders of the patient’s chart and going through them. There was a lot hidden away there if you took some time. Of course things were more leisurely then. Was I naive to think that computerization would be a time saver in today’s sped-up medical world? Seems like a lot of the advantage of having the system in the first place is being sacrificed. 

So what to do? People react very negatively to more written rules and policies that can get them into trouble, and those paper documents or PDF’s tend to sit ignored in their drawers or folders. Ultimately a sea change of everybody’s thinking has to happen if this sort of a system is going to work. Everybody has to think more about the big picture and the next step down the line and take the responsibility to get important information up where people will see it. 

Right now I’m just trying to get people’s attention. If they realize the problem with data holes, maybe they’ll recall that famous first rule about them. And first of all, stop digging.

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

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June 7, 2013 Robert D. Lafsky, MD No Comments

The Skeptical Convert 4/5/13

Dispatch from the Beachhead

I’ve had a weekend to recover now, but on Friday, seven days into the Epic go-live (including the go-live weekend as the GI on call) I felt like Tom Hanks 20 minutes into “Saving Private Ryan.”

The D-Day analogy is actually pretty useful for both the negatives and the positive of the experience. The plus side is the incredible massive force brought to bear on the project — people everywhere, hardware guys, red-jacketed helpers, administrators, docs from the Big House, sometimes actual Epic people. The system was going live simultaneously for two community hospitals, but ours had the empty space for 140 call-in workstations, and when I went by there last week, every one of them was occupied. And so when I needed a beachmaster, I could walk on over there to find one without getting shot at (at least not yet). 

But even with massive firepower from the Navy and Air Force, the troops still had to take Omaha Beach. And every clinician seem to have reached that moment where he was hunched behind the seawall wondering how he would ever get out of this situation. 

Everybody survived, though, more or less. There was plenty of help from the red vest people standing around, although mostly of a very specific ground-level nature–sort of like the Bangalore Torpedoes that get way too much credit in all three of the cinematic depictions of Omaha Beach that I’ve seen (“Ryan,” “The Longest Day,” “The Big Red One”).

But historians say it was the individuals that were able to call in Naval artillery, and the ship commanders who responded with precision fire who turned the tide, and in my own (OK I admit overglorified) way, I had to find higher level people with a big-picture grasp of the situation to solve most of the problems I encountered. 

I know, I’m over the top, but I can carry this analogy further. The massive pre-landing bombing that fell behind enemy lines reminds me in a way of much of my 16 hours of training, with what in my ground-level opinion was overemphasis on detail (bombs/process) and not enough on fundamental principles (target/fundamental concepts).  

For example, in my training as a “surgeon,” with a lot of work on how to work the pre- and post-op navigators, there was no mention of the fact that apparently because of a fundamental issue in Epic, I wouldn’t see those navigators automatically if I opened up the patient from the inpatient list instead of the surgical schedule. 

But enough carping. The beach is secured, the smoke is clearing, the beachmaster did in fact show me how to get that navigator up from the inpatient list this morning. There are a lot of other details that will take months to figure out (I just discovered the existence of sticky notes about five minutes ago). But I’m up and walking forward, however shakily. Onward to Berlin. 

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

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April 5, 2013 Robert D. Lafsky, MD 2 Comments

The Skeptical Convert 3/22/13

Weed’s Problem

After a week’s worth of somewhat manic narratives from HIMSS, recent HIStalk posts have taken a darker turn toward the adverse effects of the computerization of American medical care. Travis Good’s depressing story about his wife spending 2-3 hours a night catching up on data entry fits nicely with Ruth Bowen’s excellent piece on how her personal medical record has been chopped up and pureed by multiple competing and non-cooperating EMRs (this piece was so good, in fact, it really belongs on The New York Times op-ed page). 

I read HIStalk to get some measure of insight into a process that, like it or not, is transforming medical care. But the sense of fragmentation and chaos is demoralizing to many clinicians who do have some sense of — or at least a healthy degree of respect for — high-level degrees organization. And I mean more than just organization of our “workflows”–I mean organization of our thinking itself. We need a big thought leader, someone like Larry Weed.

Yes, those were heady days back in the 70s. Although it’s not true that there was never any serious thought given to the medical record before Weed (I recommend Eugenia Siegler’s excellent piece in Annals of Internal Medicine, unfortunately paywalled, on the stepwise and incremental developments in this area starting in the 19th century.)

Weed brought an evangelist’s zeal to his presentation of a comprehensive vision for using the medical record to transform the process of diagnosis as well as the management of treatment. It’s a shame we don’t have him around any more–he sure would have a lot to say about how things have been going lately. 

What’s that? He is still around? And he has a book out?  Funny, I haven’t seen much about it in the medical journals or the lay press. Reading this site you might get the impression he was long gone.  

But a title like Medicine in Denial seems designed to get some attention. Maybe the fact that the book has no publisher’s imprint and was copyrighted under the Creative Commons explains why we haven’t seen much attention paid.

But it, like its author, is a piece of work. You can call it a polemic, but Jeremiad gets more to of course referencing the angry language in the Book Of Jeremiah — and if that brings to mind Samuel Jackson in “Pulp Fiction” reciting those verses while pointing his Star Model B at you, well, might not be too far off.  

In fact after reading the book, my sense is that Weed would be happy to see a lot of people doing very well in the HIT field selling pencils at the corner. But don’t worry, he’d also be glad to put a lot of overeducated cognitive specialists like me right there with you competing for sidewalk space. 

But is the book any good, and does he really have any answers that work in 2013? It’s going to take more than one of these short-format pieces to get into that. This will take a bit of time, and I have a day and-sometimes-night job, it seems. But stay tuned — more will be forthcoming.  

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

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March 22, 2013 Robert D. Lafsky, MD No Comments

The Skeptical Convert 3/11/13

Four-Letter Words

An EMR can work well but it can work not so well. I want to try to show you what I mean and not tell you, so I will do this with no words that are long, no more than 4 type hits per word. Why do this? In my head I know why but it is hard to say here just yet. And you can see now how hard it can be to work this way, but I will try to keep to my task.

When you use an EMR to pick out words you want to pick them off of a list. This can be easy if you do not know how to type, but it is not easy to say what you mean all of the time. A list may take you down a road you do not want to go onto, and the way they set an EMR up, a word down the line may not fit with the word up at the top. I see this all of the time when I do my work on the gut and find  a word that is what I want to say, but up over top of it is a word I do not want to say and I can not get out of it.

But what is good when you use a list like that is that all who use it have some way to do it in the same way. They may not all do that but they can do it if they want to. Thus there is some way to make the word sets look and feel the same, so that when you look at it you know where to look to see what you want to see when you want to see it. I also like it, when I work, when I can see what I do, and go back and fix it when I want to say more of what I get in my head as I work.

The idea here is a very big idea and many have had much to say on it for many a year, back more than the year one AD in fact. But I go on too far away from my goal.

On one side I want all the word sets to look and feel the same, but on side two I want to say what I want to say that only I can say. What to do, EMR man? I see that you set it up so that I can do them both if I want to. Is that good? Do we do more good if we all look the same, or do we do more good if some do it a way that they want to and some do it a way that they want to. Is it good to read talk in a way you do talk, or to read some talk in a way you do not talk? I do not know.  

But it can be a good thing to work with a limit.

Oh hell wait…

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

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March 11, 2013 Robert D. Lafsky, MD 4 Comments

The Skeptical Convert 2/20/13

February 20, 2013 Robert D. Lafsky, MD 1 Comment

Angry Birds vs. The Fruit Altimeter

A man’s reach should exceed his grasp, or what’s a metaphor? Marshall McLuhan

I love a good metaphor as much as the next wetware-based concept processor, and Jonathan Bush’s labeling of Epocrates as “Angry Birds for healthcare” was a particularly clever one. But is it a useful one?

I was an early adopter of Epocrates on my Palm III (now bricked, and yes, there I go) and it quickly became indispensable in my everyday professional activities. For decades before, the only way to look up a drug information you didn’t have memorized was to haul up your giant copy of Physician’s Desk Reference and tediously turn pages. 

What you got there was a small-print version of the complete prescribing information, with every lawyer-generated factoid laid out horizontally. Useful things like the, uh, dose were hidden deep inside somewhere. So yes, I get the metaphorical point — quick, intuitive, easy to use, everything you need right there.  

The difference between Epocrates and Angry Birds, though, gets to the fundamental reasons for their popularity. The actually better comparator for the avian slingshot game would be Windows Solitaire. Because in both cases, new operating system technology required the use of new tools and/or techniques for on-screen manipulation, and both applications made learning of these techniques fun, although in both cases, unfortunately, time-wastingly addictive. Nobody sits for hours mesmerized by ePocrates. But that’s because Epocrates wasn’t about technique, it was about information.  

Which gets to that other metaphor you hear so much, the one about the tree with the fruit on it. We speak of “going after the low-hanging fruit” as an opportunity to get or accomplish something worthwhile and/or profitable with a relatively low level of effort. In this context, I suppose you can argue for applying that metaphor to Epocrates.

For the practitioner, drug information was well up in the middle of the tree, not difficult to understand per se, but difficult to reach. Epocrates put that information in your pocket and organized it the way a doctor thinks. Most drugs you prescribe are not new to you, but you need to check the dose quickly, or the pregnancy warnings, or answer a question about side effects. They organized perfectly for that, with categories that were clear and logical for us. At a basic mechanical level, they made it lower-hanging fruit for the doctor, which made it worth so much to Mr. Bush.

But there’s another side to this.  I doubt that the fruit was hanging quite so low for the developers. I’m sure designing the program, writing the code, and debugging it took a lot of work. I don’t know how much effort it was to take existing data and put it into a format that could be used by the new app. But the information had been digitized already, and to the practitioner it seemed like everyone else had digital access to it and was using it against you — the outside pharmacist telling you you wrote it wrong, the hospital pharmacist telling you it wasn’t on the formulary, the benefits person saying it wasn’t covered. Endless pages. They were throwing the fruit at you. At least if you could grab some and fire it back, you had more of a fighting chance.

With a slingshot motion, I guess?  OK, the fruit’s fermenting and I’m getting dizzy.  But I often wonder why the argument for improved control over already-digitized processes isn’t used more to motivate doctors to embrace CPOE. I’ll work on that one when the fire department comes to get me out of this tree.  

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

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February 20, 2013 Robert D. Lafsky, MD 1 Comment

The Skeptical Convert 2/4/13

February 4, 2013 Robert D. Lafsky, MD 2 Comments

If you were my patient and I mentioned to you that it wasn’t until recently that I found out that blood circulation was how you get oxygen to your body parts instead of absorbing it from your skin, what would you think of me? I think you’d politely excuse yourself and leave. Because although I specialize in gastroenterology, I as a doctor am supposed to have an understanding of how the whole body works. I’m not supposed to see it as some mysterious black box that I had to learn to deal with by rote.

When I talk to a cardiologist about a case, he may not go as far into physiologic details with me as he would with another heart specialist, but he will refer to general principles that we all learned earlier in our education and training, to orient me to at a reasonable level of understanding about what is going on and what needs to be done.

Right now though this concept doesn’t seem to apply much in the medical computing world.  By way of an example, I direct you to a study and editorial in the January 15 Annals of Internal Medicine. The original study looked at Meaningful Use measurements in practice by going back over the actual records.

The authors documented a statistically “wide measure-by-measure variation in accuracy” that “threatens the validity of electronic reporting.” I know, that’s no big surprise to any regular reader at this site–file it under “Department of Duh.”

The accompanying editorial caught my attention, though.  It was written by a distinguished general internist, trained at top institutions and a university medical faculty member. She wrote very well, and with a knowledgeable authoritative tone, about the problems with getting statistically valid data out of multiple sources, users, and formats.  

Right in a middle paragraph, after a general comment about about how variable use of the EHR by different providers increases “measurement noise”, she noted a striking personal example, and I quote: ”In my own practice, I learned that my lower rates of blood pressure control reflected the fact that I was documenting the patient’s blood pressure in free text rather than using an available structured field.” And then back to the general subject.

Wow. It seems to me that that deserved more discussion. OK, maybe she didn’t know they were tracking blood pressure in the first place. Maybe she assumed the system had the ability to capture that information from a text entry by some sort of NLP process. I’d like to know that, but I’d also like to know if she understood at that point about these things called databases underneath applications — that they store different categories of data, that they treat numeric data differently from text, and how numeric data generally needs to go into structured fields for that to happen.

Because I can tell you, from lots of personal conversations I’ve had, that whether she did understand those basic concepts or not, plenty of other medical practitioners don’t. That was worth discussing at greater length, whichever of those theories or combinations are true or false.

Why? Because if medical practitioners, as users, are going to see HIT as an alien world only approachable by rote training, they’re going to fall into potholes like this all the time, and I see it happening a lot.  There are a lot of lousy EMR designs out there, and a lot of mediocre training, but I can’t help but think that at least some of the problems with usability stem from gaps in basic user comprehension of the bigger picture.

David Brooks said it well the other day. “Change is hard because people don’t only think on the surface level. Deep down, people have mental maps of reality — embedded sets of assumptions, narratives, and terms that organize thinking.”  

That’s what happens when I’m talking to the cardiologist. Deep down, we have a common map of reality in our heads. That’s how we organize things in our minds and how we think. We’re here in the first place because that’s what we’re supposed to be able to do.

I read a lot of naysaying on this site about the computerization of medical practice, written as if it could all go away.  It’s not going to, but what we have right now isn’t working very well. Part of the solution will be for the mental maps of HIT people and physicians to match up better. The physicians do need to accept that their mental maps are going to need some revision. The IT people need to realize that we need explaining to get the training to sink in.  

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

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February 4, 2013 Robert D. Lafsky, MD 2 Comments

The Skeptical Convert 1/25/13

January 25, 2013 Robert D. Lafsky, MD 4 Comments

APSO Fact and Fiction

I sit on an Epic implementation advisory committee for my hospital’s multi-hospital organization. From time to time, we are asked to make policy recommendations. One issue brought to our attention concerned the formatting of medical assessment notes, especially the part where the practitioner actually gets around to stating his or her actual opinion about what’s going on and what to do next. 

The issue had to do with whether that information would be placed at its usual seat of honor at the end of the report, or whether it should be placed up at the top. The shorthand for the formatting issue would be “SOAP vs. APSO”, where the four letters stand for “subjective, objective, assessment, plan.”  

In medical school, we are taught the traditional “history and physical” reporting format when evaluating a new patient or problem. The patient’s own story comes first– information considered “subjective” (yes, you can argue that the subjectivity is as much in the head of the practitioner as the patient, but a digression here). What followed traditionally was a detailed physical examination.  

In the mid-20th century, Lawrence Weed, MD coined the SOAP terminology, incorporating the reality that lab tests and imaging had become major factors in the medical workup. “Objective” became his bucket term for doctor- and system-generated information beyond the patient’s history.  

But whether you call the next section “impression”, “assessment” or “differential diagnosis”, the question it attempts to answer is the whole point of the exercise. What, doctor, is your opinion about what is going on here? What do you think is wrong, and if not that, what else might it be? The plan for what to do, of course, should follow logically from that.

The argument of APSO proponents is that they don’t really want to change this, but that EMR reports have become bloated by lots of templated and imported information. Someone reviewing them just wants to get to the conclusions and recommendations of the attending or consultant. So, put that at the top. Their position is that no matter how you format the information, the workflow and “thoughtflow” (a nickel to Dr. Bierstock) stay the same.

Is that true? I have trouble believing it. In fact, deep down I really dislike the APSO format, and I didn’t like it before any computerized reporting was developed. 

Many practitioners, especially medical subspecialists, dictate their consult notes that way. They’ll say they work in their heads down from the subjective / objective, but when they dictate, they do start with the conclusions. When I read down the page of an APSO consult, I often see gaps in basic structure and/or clinical information that may have been included if the author had stayed in order. From my own experience, dictating in traditional order, I do in fact sometimes revise my opinion or add additional diagnostic options by the time I get to the end.

But really, I can’t get that worked up about it (that’s why I dumped my original title:  “Let’s send APSO to Lhasa”). The reason is that APSO notes at least have some sort of thought-through assessment in them. Frankly I read a lot of notes that dutifully go through the motions of a history and physical, but then the conclusion — often compressed into some ghastly mutant section called the “Assessment/Plan” — blandly restates the available findings and problems and goes straight to the tests and consults that will be requested. If you have nothing to say, you might as well spit it out at the beginning. Saves time for me, anyway.

Will Epic straighten these problems out or exacerbate them? I’m out of space now, but Epic go-live is in two months. Stay tuned.  

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

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January 25, 2013 Robert D. Lafsky, MD 4 Comments

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