Jonathan Kurland Wise, M.D., F.A.C.P. (Harvard College and Medical School, Clinical Professor of Medicine at Tulane Medical School)
and Mark Sullivan (director and writer at manhattanliterary.com)
WHAT HAPPENS WHEN EBOLA MEETS A FEDERAL REGULATORY BUREAUCRACY THAT IS OUT OF CONTROL?
The American federal government and our legal system have made documentation more important than Good Clinical Practice. This deprived Mr. Thomas E. Duncan of a better chance to survive Ebola, and it drives fear into the Dallas community that the deadly disease will now spread through their city.
Making documentation the highest priority in a hospital or medical office contributes to the deterioration of the practice of medicine, while, paradoxically, increasing its cost significantly. Clicking boxes in the Electronic Medical Record (EMR) has become more important to a provider’s practice than thinking. This happens from moment to moment in the new environment, but only becomes obvious to the public when patients read their own medical records and realize that they may never have answered such a question, and that, to their bewilderment, the record has little to do with them.
But now, as the basic problem explodes into public awareness, one has to look with dismay and fear at the horrendous handling of a patient seen in the ER at Texas Health Presbyterian Hospital, Dallas. Mr Thomas Eric Duncan (deceased yesterday) was sent away despite being infected with the Ebola Virus. And this happened in a city already targeted as an Ebola risk, putting all others at risk.
So, what actually happened?
In a Bloomberg article written a few days after the mistake, Mr. Wendell Watson, the appointed spokesman for the hospital, did something very curious. He began by pointing to the Electronic Health Records (EHR) system as the sole cause of the communication breakdown — the fully computerized system that has replaced old hand-written charts and verbal communication inside a hospital’s units.
“Wendell Watson, a spokesman for the hospital, said the hospital had wrongly designed its digital record system so not all of a nurse’s notes are visible to doctors.” (http://www.bloomberg.com/news/2014-10-03/electronic-record-gap-allowed-ebola-man-to-leave-hospital.html)
But then Watson quickly reversed this statement and ended up defending the EHR system, blaming by implication an individual physician.
“As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow,” Watson wrote in the e-mail. “There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.”
Which version of his story was true? The first one.
* * *
It is quite possible, even likely, that the physician failed to see in the Electronic Medical Records (EMR) that the nurse who first saw Mr. Duncan noted that the febrile patient had recently arrived from Africa.
How could a competent Dallas doctor fail to see that? Instead of getting a red alert, the Patient was sent home with routine orders, and between then and his return to the Hospital the next day he may have infected others with the deadly virus. The problem lies not with individuals, but with a System embraced by those in power with little or no direct clinical experience.
With the abundance of material that the EMR or EHR almost automatically spits out it is no wonder that important facts are buried under the junk. One sees only a clutter of trees and misses the forest. As described in our book The Decline and Fall of American Medicine, Clinicians have complained for years that it is difficult to even understand, at times, why a patient was admitted from the emergency room into the Hospital.
The EMR is so convoluted in detail — detail contrived by clicking a “review of systems” and other less than critical data that one has to read page-after-page in order to get some idea of what the emergency room doctor was really thinking; or why he or she decided that in-patient care was even necessary.
This is a time consuming and very costly process in an arena where you have little time (you can be dealing with life and death decisions) and wherein systemic expenses have reached a breaking point. Being an ER physician is usually a busy and very stressful job. Most doctors working in the trenches will see this actuality from a mile away: that the ER Physician probably had a great deal of superfluous data to sort out and missed a key fact. This happens all the time. But, again, this time it became public knowledge because Ebola is a deadly, high profile disease.
So, why are physicians and nurses putting so much superficial and frequently erroneous data into every patient’s record? Why does the most experienced RN in a hospital unit sit in front of a computer all day long, with little break, inputting data fed to her by Nursing Aides with far less ability who enact patient care in her place?
FOLLOWING THE MONEY
Medicare payments are based on quantity, not quality. For example, the ER in Dallas would be paid more for long, largely automated EMR with an incorrect diagnosis than it would get paid for a short, written note by the physician with the correct diagnosis. Payment in an office setting is also based not on the diagnosis but on several clicks that spit out a long “review of systems.” (Systems means GI, pulmonary, cardiovascular, etc.) There are 8 main systems in the human body, and the more you “review” in a superficial way (superficial because you are often trying to focus on a core disease for diagnostic reasons) the more you can bill.
The relatively new payments based on Obamacare’s “Meaningful Use” makes documentation derived from some click on the computer even more imperative. In other words, clicking some preordained template put together by the hospital and some distant EMR corporation like Epic or All Scripts or IBM, is the key to financial success. Money earned here truly has become the equivalent of documentation. But, the amount of time and effort wasted can destroy providers, and quite possibly it could now needlessly spread Ebola around the USA when this could have been avoided by routine precautions in the older system — like a nurse walking up to a doctor and telling him something important. You see, the assumption now is that if an important fact has been typed into the system, it is visible; not that it is likely just one item buried among hundreds, so many of them meaningless to acute care.
An expert medical secretary shines some light on Meaningful Use, the new mandate. Use it, or lose your practice in a few years:
At each stage of the new “Meaningful Use,” mandated under Obamacare, you must meet certain percentage measures…
We started this shift to electronic medical records over a year before we even began thinking about attesting for this “Meaningful Use,” which is the government testing us, ready to withhold money if we fail. We took the time to figure out how you have to do certain things, in order to make sure we would achieve the percentages the government demands. If we continue with the system as it is supposed to work, the front office staff will see a reduction in their work, because the bloated charts will be at our fingertips.
The doctors, on the other hand, are the real losers; and by consequence, the patients. The doctors are stuck with the excesses of the new system, especially the more careful doctors. They will not see a reduction in time, unless they get better at clicking buttons…One of the doctors put it in perspective. ‘Before these electronic records to achieve “meaningful use,” a patient would come in for his appointment and the doctor would ask him relevant questions based on clinical experience, and then decide on the appropriate treatment. Now, if a patient comes in with a complaint of a sore toe, you have to do a review of symptoms designed by a bureaucrat that asks everything unrelated. Has she had an eye exam in the last year? Is she is anxious or depressed? Her date of menopause onset? Is she is incontinent. Menus lead to other menus. The questions go on and on. They derail the earnest search for a diagnosis.’
The secretary with 20 years experience makes another very important point: “We thought the medical assistants could help by doing the review of systems, but the doctors feel if they themselves don’t do a review, then they don’t know what is going on with the patient, and don’t feel a medical assistant would pick up on something subtle the patient might say that would indicate another problem…It is all time consuming and has nothing to do with the patient’s complaint. But when you print out the electronic note, it’s really impressive. You get 4 or 5 pages of mostly useless information, but it meets the requirements of Meaningful Use.
At the end of the day, I don’t think patients really like the electronic records because the doctor is so busy typing and not really talking to the patient. It’s amazing, the difference in how a doctor and pt. now meet. Amazing that they even put up with it, but it seems both are getting used to it. (end quote)
This provides a decent picture of the bureaucratic nightmare doctors now face. One has to wonder if the nurse who contracted Ebola from Mr Duncan is getting used it all? We contend that without the all the useless pages in his EHR, Mr. Duncan would have had a better chance, his nurse might now be healthy, and Dallas would not be on edge right now, wondering who else will get sick and die.
Unfortunately, the old adage, “If it is not documented it did not happen” should now be reversed. The unsubstantiated garbage that is now coming out of a hospital’s computer makes this statement more accurate: “If it is documented, it is very possible that it did not happen.”
It is not surprising that the bureaucrats that now want to run the show have clung to this old saying because that is what bureaucrats do. Now, there is more paperwork and that means more bureaucratic jobs.
Furthermore, medical malpractice lawyers have something to gain with excessive information. In their wildest dreams, they could not have wished for a more profitable system for their own profession. This is so because the doctor often has just a few minutes to come up with a diagnosis and treatment plan in an acute event, whereas the lawyer can now bask in legally binding EHRs. Ever-increasing EHR mandates almost always leave gaps of substance in a record, one lawyer told us recently. The substance, as we keep saying, can often be hard to find. The printed pages of the electronic health record are a field day for the malpractice attorney, because the protocols that produce their content were not designed by doctors. The experienced doctor’s mind is largely absent from this bureaucratic process.
Also, the cost of such a flawed program is astronomical. We are paying several billions a year to the companies that developed this software. Why didn’t the Feds develop their own software — not only to cut costs, but to make a unified system so that every office and hospital could communicate properly with each other? Instead we have different gauges of railway track, so to speak, named IBM, Cerna, Epic, GE, All Scripts and a few others that do not interconnect The train carrying the patient’s medical records reaches the end of the line at the terminal for each separate system.
One unified system: what a powerful tool this would be for treating patients! Why do we pay over 30,000 dollars to every single practicing physician to employ such a system that is necessary for the development of Meaningful Use, which reminds most of us doctors of the kind of abuse we suffered in junior high school.
Above all, why isn’t the physician paid according to the diagnosis, instead of how much clicking and clucking he or she is prone to do? (A hen could possibly make a fortune.) Again, enforced bureaucratic behavior replaces medical training and experience. Bureaucracy, as usual, replaces thought itself!
The answers to these questions are very disturbing. They have nothing to do with good clinical practice. Instead they are based on Greed at almost every level. And such a System based on Greed has led to repetitive failures, including the one in Dallas.
* * *
To return to which of Mr. Watson’s answers is more likely true:
The bureaucrat or lawyer or legislator would likely miss the subtlety of Watson’s contradicting statements. Only the doctor in the trenches can see the entire calamity for what it really is. This doctor, working day in and day out in his or her office, struggling with the increasing workloads demanded by EHR, going into the hospital as an attending or doing consults for other MDs — would understand with lightning rapidity Mr. Duncan’s release into the population, and Dallas’ new risk. The experienced, working doctor would be able to answer the riddle of Mr. Watson’s statements about EHR, when Watson first blamed it and then protected it a few hours later.
This same doctor, let’s call him Holmes, would say: “Watson realized the hospital’s mistake in criticizing a multibillion dollar systemic problem — inside a system that organizes all of their cash flows. It is almost like coming up against the A.I. named Hal in 2001: A Space Odyssey. In a hospital, the computer handles the major operations of the spaceship, so to speak. Above all, it handles the billing when it interfaces with all the insurers and the government. Its operations provide the hospital’s paycheck. To call the EHR system into question could well mean stopping the cash flow. This doubt would also make people aware that the hospital has a serious, systemic problem. So, they decided to protect their EHR software and instead throw a doctor and nurse under the bus to cover it up.”
Better to sacrifice a few staff members than the monolithic regulatory system that is out of control. People don’t matter much anymore. It is the computer that gets you paid. Just about everyone on the inside who is educated and fully conscious knows and struggles with this reality. And the reality is getting worse by the year.
A top neurologist, who prefers privacy, had this to say: “Under Obamacare, the bureaucratic regulations have soared and are debilitating. They hammer the ability of any serious person to navigate and work through the system.”
He got quiet for a moment, and then added: “What scares the daylights out of me is what if bureaucrats manage to break the system? How would you put it back together, something so intricate.”
That is, our medical system with its deep reservoir of specialists, the best in the world and at its peak only about a decade ago — accrued over so many decades inside a culture more fixed in science and learning, and less in federal control and bureaucracy. Let us all heed the saying, “Once the glass is broken, it is hard to put it back together.”
EHR as it now exists is a nightmare for doctors, and a disadvantage for patients. Could it be a good thing? Yes, if it gets redesigned by doctors who work with it every day.
For now, the greed of billion dollar businesses and their paid politicians and court intellectuals seems to have prevailed, and a nurse is now dying of Ebola in an isolation ward in Dallas
At the start of this article we wrote, “The problem lies not with individuals, but with a system embraced by those in power with little or no direct clinical experience.”
To fill that in: the arrogance of those who make the policies the rest of us have to live with, the ones David Halberstam once called “the best and the brightest” must have said to themselves, “How can we establish control and use our wonderful, brilliant knowledge base to bring order to the rest of the disordered world?” And they applied this logic to American Health Care.
When you start with that kind of arrogance, you get rubbish as the result. You get the last few weeks in Dallas. And then you get the mind numbing realization that this same excessive, and, for now, horribly flawed system is in place all over the country.