Curbside Consult with Dr. Jayne 12/29/14

Whenever something happens with our EHR that physicians don’t immediately like, there is bound to be grumbling. Sometimes it doesn’t even have anything truly to do with the EHR, such as a change in requirements for Patient-Centered Medical Home recognition or with Joint Commission accreditation.

Physicians and clinical staff would have had to comply in the paper world, but they don’t see it that way. They seem to perceive such mandates as uniquely burdensome and EHR related despite our attempts to educate.

We’re going through one of those periods now. Our accountable care team has decided that we need to collect certain information in a specific way that doesn’t fit very well with some of our workflows. That’s the problem in an organization like ours – each hospital has its own CMIO, but we don’t have one over-arching person who can cut through the noise and make decisions that fully take into account the limitations of our various systems and vendors. The accountable care team has good intentions, but I doubt half of them have even seen the workflow of some of our clinical systems.

On the ambulatory side, we’re trying to make it as smooth as possible, even using some programming sleight of hand to get the data into the right format without clinicians having to enter it twice. The problem of non-clinicians dictating data that clinical staff must document certainly isn’t new. It goes back to the creation of ICD codes and E&M coding requirements. Anyone who has ever had to formally diagnose a patient with “Bone and Mineral Disease, NOS” rather than osteopenia simply to get it billed will know what I’m talking about.

In some ways, Meaningful Use has helped with this, allowing us to use SNOMED codes to capture that level of clinical granularity. We do still have to translate them into billing codes, however, resulting in parallel diagnosis lists in the chart. That can have issues as well.

When we first started using SNOMED, we found out there were issues with some of our mappings to ICD-9. As long as the data flowed from SNOMED to ICD, we were fine. But if clinicians tried to pull diagnoses off the billing list and convert them to SNOMED, detail was frequently lost.

Physicians immediately jumped on this as a patient safety issue. The financial team jumped on it because the loss of specificity could lead to decreased reimbursement. Those two forces combined made it easy to get access to resources to fix the problem quickly. One of our most vocal EHR haters used it as a reason to again call for discontinuing use of the EHR because of its many safety flaws.

We hear that chorus all the time. Although there are many valid points about EHR design and patient safety, there are also numerous points where EHR makes our work safer as well as more efficient.

I was thinking about this last night as I worked in the ER. There is a great deal of attention to EHR-related patient safety and people are always crying out for regulation. How much attention is there to financially-driven patient safety risks?

One of the patients I treated was a prime example of what happens as more and more of our decisions are financially driven. The patient was a young woman who came in because she couldn’t reach the on-call nurse covering her case. That’s the first point of failure – that physicians are no longer taking their own call because it’s more cost effective (and burnout reducing) to have a nurse cover your call.

Unfortunately, she has four different specialists involved in her care and didn’t actually have a problem that we could address in the ER. Her condition is complex and still partially undiagnosed. Her visit was more about coming to us as the place of last resort. She thought that if we tried to call her specialists, we’d have some magical ability to get her some answers.

If she had come into the medical system when I was a student, she would have been admitted to the hospital until the full workup was complete and we had a plan of care. Each of her specialists would have seen her daily and seen each other in the halls and at the nursing station. However, it’s cheaper to care for people as outpatients, so money was saved by sending her home. Unfortunately, her care was fragmented by this decision – the second point of failure.

During the course of her care, she developed a serious infection that required weeks of intravenous antibiotics. Her insurance company has a policy that patients under Medicare age be “trained” to administer their own infusions at home to save on the cost of the home health nurse. There is no regulation in my state about this practice, which gives payers the ability to make these determinations.

Apparently the patient either didn’t understand or didn’t receive the information that the antibiotic packets had to be kept refrigerated. When she went to the infectious disease physician’s office each week to have her IV line and dressing checked, it didn’t come up there, either. This resulted in the patient infusing 21 days of non-effective medication, which likely contributed to the recurrence of her infection, which was why she was in the ER — she was worried about whether it was extending.

Failure point number three is assuming that just because it’s statistically likely to be OK to allow a patient to administer their own IV antibiotics, that doesn’t make a clinical treatment plan applicable to all patients.

For each person demanding regulation of EHRs, where is the demand for regulation of situations like this? She did determine five days ago (after talking to the on-call nurse about her IV line) that the medication had to be refrigerated and a new supply was sent out, but the infection isn’t looking any better, which was why she was trying to reach her physician in the first place.

In talking to her, I struggled to figure out the best person to call. The infectious disease specialist was out of the country. His primary nurse had gone into labor and was being covered by a nurse who initially told the patient to call the surgeon and then didn’t return subsequent pages. The surgeon was also out of the country, but the patient didn’t think he was the right person to call since he wasn’t involved in the antibiotics. The primary care physician hadn’t seen her in six months. The other specialist involved is a plastic surgeon, who wouldn’t be of much assistance in this situation.

Failure point number four is lack of ownership of this patient and her complex situation, again in part due to cost-cutting maneuvers. Physicians just aren’t likely to spend hours playing phone tag with various specialists when that time isn’t reimbursed and payments are being cut.

I had the charge nurse put out a couple of pages to different specialists involved in her care, figuring there was an equal chance that whoever called back wouldn’t know anything about her, so might as well cast a broad net. In the mean time, I went back in and looked at the patient’s medication that she had brought with her. Sure enough, nowhere on the labeling did it indicate that it was to be refrigerated. It was from a compounding pharmacy contracted by an infusion company contracted by the insurance company. Many cooks in the kitchen always make for a questionable dish.

Ultimately one of the infectious disease nurses called back and we made a plan for the patient. Since she was clinically stable, fever-free, and had no new symptoms, she was stable to go home and the nurse would see her first thing the next morning. I reassured the patient and explained that our goal in the ER is to take care of any critical issues and make sure that patients are stable and that follow-up has been arranged. I chose my words carefully. Usually I say something about making sure any life-threatening conditions have been addressed. In this situation, there are still multiple factors that may threaten her health (and ultimately her life), but they were completely beyond my scope.

I’ve been thinking about her all day today and wondering how things turned out this morning. That’s the problem with putting a family physician in the ER. I always wonder about the follow up since continuity of care is one of the reasons I wanted to be a physician in the first place.

I’ve also been thinking about the ways that the system failed this patient. I can’t help but draw a parallel to all of the people out there who think that more technology is going to solve all the problems and that regulating the technology is the answer. Dealing with technology is just the tip of the iceberg in healthcare. This case is a prime example of everything out there that also needs to be addressed.

To the people who demand broad regulation of health information technology by the FDA as the solution to patient safety problems, I’ll get on board with that at about the same time the FDA gets oversight of compounding pharmacies, home infusion agencies, and payer executives squeezing the maximum profit out of the system. Based on the 50 patients I saw yesterday, they’re a much greater threat to patient safety than my EHR.

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