Tuesday, November 22, 2016

A Team From The US Identify A Really Key Issue In EHR Use. Food For Really Deep Thought I Reckon.

This paper was released a little while ago:

New Unintended Adverse Consequences of Electronic Health Records

Keynote
D. F. Sittig (1), A. Wright (2), J. Ash (3), H. Singh (4, 5)
(1) University of Texas Health Science Center at Houston, School of Biomedical Informatics and UT-Memorial Hermann Center for Health Care Quality and Safety, Houston, TX, USA; (2) Harvard Medical School and Brigham and Women’s Hospital, Department of Medicine, Boston, MA, USA; (3) Oregon Health & Science University, Department of Medical Informatics and Clinical Epidemiology, Portland, OR, USA; (4) Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; (5) Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA

Keywords

Medical Informatics, Confidentiality, Data Display, usability, Quality indicators, Electronic Health Records (EHRs)

Summary

Although the health information technology industry has made considerable progress in the design, development, implementation, and use of electronic health records (EHRs), the lofty expectations of the early pioneers have not been met. In 2006, the Provider Order Entry Team at Oregon Health & Science University described a set of unintended adverse consequences (UACs), or unpredictable, emergent problems associated with computer-based provider order entry implementation, use, and maintenance. Many of these originally identified UACs have not been completely addressed or alleviated, some have evolved over time, and some new ones have emerged as EHRs became more widely available. The rapid increase in the adoption of EHRs, coupled with the changes in the types and attitudes of clinical users, has led to several new UACs, specifically: complete clinical information unavailable at the point of care; lack of innovations to improve system usability leading to frustrating user experiences; inadvertent disclosure of large amounts of patient-specific information; increased focus on computer-based quality measurement negatively affecting clinical workflows and patient-provider interactions; information overload from marginally useful computer-generated data; and a decline in the development and use of internally-developed EHRs. While each of these new UACs poses significant challenges to EHR developers and users alike, they also offer many opportunities. The challenge for clinical informatics researchers is to continue to refine our current systems while exploring new methods of overcoming these challenges and developing innovations to improve EHR interoperability, usability, security, functionality, clinical quality measurement, and information summarization and display.
Here is another presentation of the same issue from the same team:

Increased Focus on Computer based Quality Measurement Negatively Affects Clinical Workflows and Patient-provider Interactions

The slow, but steady, move from fee-for service to pay-for-performance payment models in health care has given rise to more EHR-based clinical quality measurement. This push for quality measurement has necessitated an increased need for capturing complete, accurate, structured data that can easily be extracted, aggregated, and reported to administrators, quality oversight organizations (e.g., University Health Consortium), and payers – both public and private. The need to capture structured data items such as “smoking status” [47], “pain scores” [48], venous thromboembolism prophylaxis, and documentation of the need for patient restraints every 24 hours has led to many convoluted clinical documentation workflows [49]. These new workflows are not only changing the way clinicians perform their work, but they are potentially interfering with their diagnostic and therapeutic critical thinking tasks leading to serious, preventable, adverse events [50], as well as having a negative impact on patient-provider interactions at the point of care [51].
New Unintended Adverse Consequences of Electronic Health Records
D. F. Sittig, A. Wright, J. Ash, H. Singh University of Texas Health Science Center at Houston, Year book Med Inform 2016:7-12 http://dx.doi.org/10.15265/IY-2016-023
Published online November 10, 2016
Here is a link:
The essential core of what is being said is here:
“These new workflows are not only changing the way clinicians perform their work, but they are potentially interfering with their diagnostic and therapeutic critical thinking tasks leading to serious, preventable, adverse events , as well as having a negative impact on patient-provider interactions at the point of care.”
What I am reading here is that moving EHR use away from the absolute basics to support care to be doing other things in parallel can harm both the quality and safety of care as well as the patient experience of their care.
This is a very powerful idea which we need to be confident we are taking careful note of. Distracting the care focussed work flow (as with maybe the myHR) may have severe (and dangerous) un-intended consequences. I look forward to ADHA analysing the material here and making some sensible responses to mitigate the apparent risks.
Fascinating stuff.
David.

8 comments:

Terry Hannan said...

David, I have already read the Sittig et al paper and agree with your comments. I believe the publication fits perfectly into position for the ADHA and the MyHealth Record implementers to review their project and expand the communications with known eHealth experts to redefine the path of our national eHealth. The article with many others confirms (to me at least) how the MyHealth Record model is inherently defective.

john scott said...

Terry, I agree with your comments and the comments of others who have pointed out the underpinning deficiencies of the current eHealth Strategy, particularly the MyHR component.

There is a way out of this mess if the Commonwealth is prepared to re-open the conversation and admit other knowledge and expertise.

If such a step were taken it would enable the necessary 'cover' for a graceful retreat from the indefensible at a time when health desperately needs some good news.

The real question that has to be answered first is whether there is someone prepared to admit the possibility of a strategic change in approach. The next step would be to have a quiet conversation about what a different model might look like and why it presents a compelling case for change. I for one, would appreciate such an opening.

Bernard Robertson-Dunn said...

If you read Martin Bowles' recent speeches about the health care system you (at least I do) get the sinking feeling that they are like the drunk looking for their house keys under a lamppost at midnight, even though they were lost down the street in the dark - there's more light.

If the government were really serious about reducing health care costs they would tackle the demand for healthcare services. Let's see how they respond to the proposed tax on sugary drinks.

Bernard Robertson-Dunn said...

Answering my own comment "Let's see how they respond to the proposed tax on sugary drinks":
http://www.afr.com/news/soft-drinks-tax-would-raise-520m-and-cut-obesity-says-grattan-institute-20161120-gstq6f

"Health minister Sussan Ley said the government is not in favour of a sugar tax "at this time" and will continue to evaluate the evidence."

And if you add the statements by the rest of government e.g. "Mr Joyce flatly ruled out a sugar tax - which is being pushed by the Grattan Institute to fight surging obesity - and advised Australians who wanted to lose weight to "eat less".

He said the idea of a tax on sugary drinks was "bonkers mad but now it's getting more and more momentum so we have got to come out straight away and say, 'we are not going to be supporting a sugar tax'." "

you realise it is the same attitude as that they are trying with climate change, reject the proven mechanism of tax disincentives - use the magic of direct action.

Even if a sugar tax doesn't reduce sugar consumption and/or improve health, it would raise money to help deal with the problem. That makes it a win-win or null-win strategy.

They are happy to spend $1-2B on a health record that doesn't seem to have delivered anything, but won't even consider something that others are doing and which can help fund healthcare.

Apologies if my exasperation is showing.

Terry Hannan said...

In response to these enlightened comments there is this article from MEDSCAPE
Medscape Public Health: COMMENTARY Sugar Is the New Tobacco, so Let's Treat It That Way. Aseem Malhotra, MBChB, MRCP Disclosures | October 31, 2016
http://www.medscape.com/viewarticle/871064

Bernard Robertson-Dunn said...

Thanks Terry, a very useful reference.

This is most telling "We mustn't forget that the substantial decline in tobacco consumption in the past three decades, which was the single most important factor driving a decrease in cardiovascular mortality during that period, only happened after legislative measures that targeted the affordability, availability, and acceptability of smoking"

There seems to be two choices:

1. Target the affordability, availability, and acceptability of sugar.

or

2. Give everyone access to their health record (most of which will be empty and/or out of date) and hope that they have the willpower, incentive, skills and knowledge to manage their own healthcare in the face of lobbying and insistent advertising from the sugar and fast food industries.

There is evidence for the first and nothing I can find for the second. And we know how keen Minister Ley is on evidence.

Dr Ian Colclough said...

Australia led the world in changing community attitudes with the introduction of seat belts, 0.5 alcohol limits, removal of advertising on cigarette packets, to name a few. 6 teaspoons of sugar in a can of coke, with some frozen drinks containing more than 27 teaspoons. We worry about climate change for the health of the world but not about sugar for the health of our people.

Anonymous said...

Just be careful, as a doctor giving dietary advice you are at risk of a caution from AHPRA. I suspect they were setup by the same people that gave birth to NEHTA!

http://www.nofructose.com/introduction/help-be-a-voice-for-lchf-after-gary-is-silenced/