Friday, May 19, 2017
These Are Some Thoughtful Pieces That Needs To Be Further Discussed And Considered.
These appeared last week.
May 9 2017, 3:00am
In more ways than one, medicine is dying.
A 2015 article in JAMA: The Journal of the American Medical Association suggests that almost a third of medical school graduates become clinically depressed upon beginning their residency training. That rate increases to almost half by the end of their first year.
Between 300 and 400 medical residents commit suicide annually, one of the highest rates of any profession, the equivalent of two average-sized medical school classes. Survey the programs of almost any medical conference and you'll find sessions dedicated to contending with physician depression, burnout, higher-than-average divorce rates, bankruptcy, and substance abuse.
At the risk of sounding unsympathetic, medicine should be difficult. No other profession requires such rigorous and lengthy training, such onerous and ongoing scrutiny, and the continuous self-interrogation that accompanies saving or failing to save lives.
But today's crisis of physician burnout is the outcome of more than just a job that's exceptionally difficult. The debate in Washington over the American Health Care Act to repeal and replace Obamacare, changing the degree of health coverage guaranteed to Americans, has monopolized our attention. But underneath, glacially slow changes to the way doctors deliver care are occurring. Medicine is undergoing an agonizing transformation that's both fundamental and unprecedented in its 2500-year history. What's at stake is nothing less than the terms of the contract between the profession and society.
An electronic medical record, or EMR, is not all that different from any other piece of record-keeping software. A health care provider uses an EMR to collect information about their patient, to describe their treatment, and to communicate with other providers. At times, the EMR might automatically alert the provider to a potential problem, such as a complex drug interaction. In its purest form, the EMR is a digital and interconnected version of the paper charts you see lining the shelves of doctors' offices.
And if that's all there were to it, a doctor using an EMR would be no more worrisome than an accountant switching out her paper ledger for Microsoft Excel. But underlying EMRs is an approach to organizing knowledge that is deeply antithetical to how doctors are trained to practice and to see themselves. When an EMR implementation team walks into a clinical environment, the result is roughly that of two alien races attempting to communicate across a cultural and linguistic divide.
When building a tool, a natural starting point for software developers is to identify the scope, parameters, and flow of information among its potential users. What kind of conversation will the software facilitate? What sort of work will be carried out?
This approach tends to standardize individual behavior. Software may enable the exchange of information, but it can only do so within the scope of predetermined words and actions. To accommodate the greatest number of people, software defines the range of possible choices and organizes them into decision trees.
Yet medicine is uniquely allergic to software's push toward standards. Healthcare terminology standards, such as the Systematized Nomenclature of Medicine (SNOMED), have been around since 1965. But the professional consensus required to determine how those terms should be used has been elusive.
This is partly because not all clinical concepts lend themselves to being measured objectively. For example, a patient's pulse can be counted, but "pain" cannot. Qualitative descriptions can be useful for their flexibility, but this same flexibility prevents individual decisions from being captured by even the best designed EMRs.
More acutely, medicine avoids settling on a shared language because of the degree to which it privileges intuition and autonomy as the best answer to navigating immense complexity. One estimate finds that a primary care doctor juggles 550 independent thoughts related to clinical decision-making on a given day. Though there are vast libraries of guidelines and research to draw on, medical education and regulations resist the urge to dictate behavior for fear of the many exceptions to the rule.
Over the last several years, governments, insurance companies, health plans, and patient groups have begun to push for greater transparency and accountability in healthcare. They see EMRs as the best way to track a doctor's decision-making and control for quality. But the EMR and the physician are so at odds that rather than increase efficiency—typically the appeal of digital tools—the EMR often decreases it, introducing reams of new administrative tasks and crowding out care. Many EMRs are designed to facilitate the job of billing before aiding in clinical decision-making. The result is a bureaucracy that puts controlling costs above quality and undervalues the clinical intuition around which medicine's professional identity has been constructed.
The EMR and the physician are so at odds that rather than increase efficiency—typically the appeal of digital tools—the EMR often decreases it.
Inputting information in the EMR can take up as much as two-thirds of a physician's workday. Physicians have a term for this: "work after clinic," referring to the countless hours they spend entering data into their EMR after seeing patients. The term is illuminating not only because it implies an increased workload, but also because it suggests that seeing patients doesn't feel like work in the way that data entry feels like work.
The EMR causes an excruciating disconnect: from other physicians, from patients, from one's clinical intuition, and possibly even from one's ability to adhere faithfully to the Hippocratic oath. If a link between physicians' computer use and suicide seems like a stretch, consider a recent paper by the American Medical Association and the RAND Corporation, which places the blame for declining physician health squarely at the feet of the EMR.
Drop-down menus and checkboxes not only turn doctors into well-paid data entry clerks. They also offend medical sensibility to its core by making the doctor aware of her place in an industrialized arrangement.
There is a great deal more here:
On a similar theme we also saw this last week:
The American Association of Family Physicians says that needs to change, and points to the kind of technology that actually enables better care.
By Tom Sullivan
May 09, 2017 11:29 AM
It’s a hard reality: Technologies that hospitals are using today do not adequately support the health of Americans, according to the American Association of Family Physicians.
“We believe that new types of information and new kinds of technology are needed,” AAFP wrote in the Annals of Family Medicine. “Technology has great potential to help foster connections and relationships among healthcare professionals, individuals, and communities, and to be a catalyst instead of the barrier it frequently is today.”
In the article, Vision for a Principled Redesign of Health Information Technology, the authors laid out a roadmap that they claimed should “form a national priority to close the gap in current health IT,” with expectations extending 10 years into the future.
The AAFP authors said in one year data visualization technologies will be central to care decisions, software will be capable of integrating patient-generated health data into EHRs, and new tools will emerge to better enable doctor-patient communications.
“We will see new technologies and new roles for technology that enable health system redesign and improvement, while supporting comprehensive payment models that focus on care delivery and health,” they said.
Looking ahead 3 years, the AAFP projected that transparent and actionable data will be widely available, including evidence-based medicine at the point of care. Technologies will also enable patients to engage in healthy behaviors and access their own medical records. And on the provider back-end, technology will drive more reliable learning within the health system.
The point here, that needs to be grasped, is that the place and use of EHRs is not settled and more work is need to really have them fit for purpose.
We clearly need EHR like applications to manage clinical information safely and predictably but just how that should work and just how they should be used is still emerging.
These articles, and many others, need to be considered and responded to in more depth than present has been the case.
Posted by Dr David More MB PhD FACHI at Friday, May 19, 2017