Monday, February 22, 2016

'Big Data' Data Quality Issues

Many attempts will be made to incorporate the use of 'Big Data' tools and techniques to obtain insights into the provision of medical care in the United States. However, as the 1st law of computer science is: GIGO (this is also the first law of archeology by the way) - Garbage in, Garbage Out, we need to discuss if their are any systematic ways that clinical practice data are systematically skewed. 

The harsh reality is the Golden Rule now rules the entire clinical enterprise. And the Golden Rule has a potent and biasing effect on data quality. 

I recall when young & idealistic that the pursuit of the best description of the patient was based on a genuine attempt to understand the patient in their enormous and at times beweildering uniqueness. 

Now due to extraordinary time constraints being leveraged against even the most idealistic practitioner & even more perniciously the gaming of the diagnosis to justify the highest DRG (Diagnostic Related Group) payments made by an ever increasing group of hospital employed physicians, I seriously question every diagnosis not made by myself.

The diagnostic related group is a payment method utilized by the payers to compensate hospitals for their care. The process specifies the number of days a typical patient with that diagnosis takes for discharge and the hospital is than compensated for that typical stay. As is obvious, a respiratory failure patient who requires intubation and mechanical ventilation for days, weeks, or sometimes for months, hospital will be compensated at a much higher rate than a patient with mild pneumonia requiring observation for 24 hours to ensure his antibiotics are effective.  

I haven't seen any patient admitted to my current hospital with chest pain who is not admitted as anything other than Acute Coronary Syndrome (ACS) . 

Their are four reasons for this. The first is that its guarantees the highest DRG payment for the hospital, secondly it means not having to justify and defend yourself for NOT giving guideline mandated best practice therapy if you diagnose the chest pain as anything other than ACS, and its turns out that you were wrong.  Increasingly emergency medicine groups are owned directly by the hospital, if the group is not owned outright, than the group is beholden to the good graces of the hospital, as their dissatisfaction with the ED physicians translates into a lost contract and a new ED group in place. While this is not universally normative behavior I have worked in some facilities where the ED physicians are tracked as too how many Medicare age patient’s they admit to the hospital and they are given admission targets (formally or informally) by hospital administration to ensure that the hospital beds are adequately filled.  

The current payment systems reward you for making the numbers come out right and that process is much more important than making the ‘right’ diagnoses. That is, errors in which the diagnosis is wrong and are felt in retrospect to be much more benign are accepted, since even one mischaracterized patient to have a benign chest pain, and who is admitted and than found with further study to have acute coronary syndrome can potentially make the hospital quality statistics fail to meet current standards since the rate of compliance for core measures for ACS has become essentially 100%. That 100% is at the price of at times massive over treatment of benign chest pain syndromes.  

Thirdly it justifies a Cath first strategy, often times directly from the emergency department, as well as lucrative outpatient advanced imaging studies and a think-second approach is adopted as these ED studies are fully reimbursed. 

Fourthly, since 25% of all malpractice claim payouts in Emergency Medicine are related to missed myocardial infarction, most emergency physicians assume the worst and admit all chest pain patients for a formal ‘Rule-out’ admission. As a consequence this force also dilutes the mix of real to non-real coronary syndromes. 

No one ever criticizes my referring emergency medicine MD's when make a diagnosis of acute coronary syndrome, while admitting obvious cases of costochondritis (rib-sternum arthritis), hyperventilation syndrome, or panic attack. Their guideline -evidence based treatment than contributes to the denominator of the appropriate quality metrics, even though in a more deliberative age a more accurate diagnosis, would not be at the economic disadvantage it currently faces. The clinical rule has become 'Not all diagnoses are created equal' and the higher the risk of catastrophic outcome, the more serious the prognostic implications of the diagnosis than the more likely that diagnosis will be utilized for the reasons I have enumerated above. 

If your looking for Nosological purity the only relevant high quality dataset probably belongs to Medicine Sans Frontier or Partners In Health. Their remuneration is not tied to the perverse 'grade inflation' I see at work every day. 

Tuesday, December 22, 2015

A Christmas Tale From Xmas Past

This christmas season, I am monstrously busy as one always gets in the health care world during that magic interval between thanksgiving and Xmas, where everybody trying to hang out until after the holidays crashes either gracefully, i.e., the 12 days before Xmas….. or ungracefully on Xmas eve. 

Apropos of nothing in particular, other than paper charts, I recall my first Xmas in medicine as an Intern on call of course on Xmas Eve…… admission at 0300 hrs……. of course it was paper documentation (I bought a 128K Macintosh as a 2nd year resident—— and suffered the slings and arrows of my staff man who criticized the purchase cause it was too expensive, a toy computer, no software, too little memory….. etc, etc, etc……oh did I mention he had is IBM XT for two weeks and working 3-4 hrs per night, still hadn’t penetrated to the Heart of DOS-ness (the technical manual was apparently written by Joseph Conrad’s Great Grandson) enough too yet successfully open and print a file……. my little toy machine allowed me with some creative application of MacDraw & MacPaint to put together a reasonable set of printed pages transformed by the copier at work into transparency overheads for a resident lecture I gave the day after getting the machine,……..) but I digress (it is in the holiday spirit of course) …….. and I was sooooooo tired that horrors, of horrors, I lost the handwritten H&P I did on the admission between 5AM when I finished it, and 7AM by rounds …. part of this was because as I was just finishing up the writing task, a patient crashed on Tele ….. I overheard two nurses complaining about a Xcover patient who had been suffering from violent nightmares all night (violent and/or dramatically colorful dreams are the classical symptom of nocturnal hypoglycemia), and now she was not very responsive to them……. asking if she was diabetic, and hearing she was, I grabbed them and went to the patient’s bedside, where she was unresponsive, diaphoretic, ashen, and pre-coding…… No IV line of course……. so, in what equals any NBA playoff Hail Mary shot from backcourt with the buzzer for 3 points, the game, and instantaneous fame (or if you’ve ever watched the unwatchable Escape from LA, Snake Pleskin’s basketball shot from one basketball basket to the other basket the length of the court, or have seen as I once saw, a Lacrosse Goalie clear his net and pitching it as hard as he could to take the pressure off his fumbling defense, thru the ball the length of the Lacrosse Field putting the ball into the opposing goalies goal with one bounce - unbelievable )…… I took an injectable ampule of D50W, frantically palpitated the femoral artery, than plunged the injector’s 18 or is it 16 G needle  into the closely opposed femoral vein, aspirated for blood….. yes it will draw up a little blood and than pushed the entire amp as the nurse grabbed a Accuchek glucose which came back unmeasurably low…….. the poor lady, began to deepen her respirations and improve her pulse amplitude, color and consciousness……. 

To get back to the workup……. when I came back from this excitement, I found I couldn’t find the workup in the chart (Cardiac R/O patient) and for the only time I was an intern, I was overwhelmed, and in a state of agitated pre-grief, as I knew I couldn’t remember one damn thing the patient told me without my cheet sheet/workup….. and I was crying from the anticipatory fatigue related to staying later than I would otherwise have to stay at least two hours latter on Xmas day (missing my oldest sons 7th and my 10 month olds 1st Xmas morning)…… Using the Wisdom of Solomon I told my attending I’d come back later in the day to redo the work…….. the nurses on the ward, tore the place apart, while I was gone, and when I returned mid-day….. I found to my amazement that they had found the workup….. which as those of us who remember not only the paper but the physical ‘charts’ and how they clipped onto the reams of paper or had various hole systems that you had to punch and line up (and the ICU had 3-hole paper punches and the wards 5 hole paper punches……. resulting in God only knows how much useless work prepunching all the papers when making transfers from Unit to Ward…… 

Why didn’t we buy universal holed papers your ask ….. it is the last great unsolved mathematical conundrum theorem …. now that Fermat’s Last Theorem and the Kadison-Singer conjecture (‘whether or not each pure state of "beta" is the extension of some pure state of some maximal abelian algebra’ (where  "beta" is the collection of bounded linear transformations on a Hilbert space” has been solved……that there is no definable mechanical punch that can place 8 holes in a top edge of a paper so that the holes line up for a 3-hole as well as a 5-hole paper chart…. the so-called Paper Pushers Topological Conundrum and Ward Clerks Full Employment Act…….. 

In any case the workup had been pushed into the patients chart probably by me, at the time of crisis, but not with the paper being placed between the retaining clamps, and when the chart was put into the chart rack (another space occupying artifact that has been replaced by computer workstations which in summation occupy at least 2^5 times the volume of the indestructible chart rack on the wards….. anyways, when the chart was placed into the chart rack, just as the gentle fall of snowflakes is a thing of beauty and magic and absorption, my precious work up fluttered silent, demure, unnoticed and uncomplainingly in the still Xmas alpenglow of morning to the bottom of the chart rack, where in the depths of this Moloch of true biblical times (Leviticus 18:21: "And thou shalt not let any of thy seeds (children) pass through the fire to Moloch”) my work up was in this Molochical beasts fire-time queue when it was rescued by the living and breathing brute-force search algorithm known as Nurse Rachetting of my acquittance and forever indebtedness……. 

And this children is how my christmas was saved from my near certain suicidial down time event precipitated by an unanticipated but well documented system feature/bugssssssssss…… which I call the God Function of the Chart Rack … No holy, no stayeee … on to purgatory…… 

Anyways, for those of you compulsively reading the time of this missive, I’ve not had my first or latest manic break with reality, I am working a overnight shift in a ’standalone ED’ which by any other name is a fancy way of bilking, err I mean billing, I mean firing up ER charge masters for what is in essence urgent care cliental and charging it big ED prices… .. since the business is predominately pediatric, there is a lull around the pumpkin-carriage changing hour lasting generally until 6AM….. 

But the associations are a bit lose as is my tongue, errrr, finger tips,  since God help me, this little corner of cyberspace has become through your kind words and indulgence in my poetical grumping about the past; I am over-joyed, over-bouyed, over-boyed, or over-achieved to consider you if not the only family I have, at least the only family I still talk too……… I am boy-ient tonight, because today I signed the Offer Letter that was sent to me by the Psychiatry Program Director offering me a slot as an entering 2nd year psychiatry resident in the program where my wife will be a third year resident 1 July 2016. I do feel a little dazed and as flamboozled as Cinderella was by her late night date AFTER the Coach returned to its essential pump-kinessence……..

At the risk of being boring, I had always intended to be a psychiatrist (the only really intellectual MD’s by the way…. except for the unusual surgeon who at his core is a frustrated historian….. all the good ones are fascinated by the history of their craft……) and I only wound up as a medical front line action hero (Cardiologist/Intensivist/ER Dude) due to my adult persistent ADHD, my personality transformation courtesy of Special Forces and Ranger training and the adrenaline to keep me going a good long time, but now I find with such universal suffering, so much media hyped angst, so much reality TV driven anxiety, so much drive to be crazy since you can’t be on the public dole for just losing the genetic lottery, or while you were talented enough to be Bill Gates, Steve Jobs, or Elon Musk you came up short on the Greed or Luck necessary to sustain the drive, so you just collapsed into a comforting haze of schizophrenic thought….. that I am going home to what has always fascinated me most in my own hopefully now longer career … the Million stories that make up the Naked City……. for it is a true beyond truth telling that Psychiatry started not with Freud but with Shakespeare who copped it from Gilgamesh, Siegfried, Beowulf, Cuchulain, & Arthur…… and that is not even recognizing the 10,000 thousands of stories from Asia/India/Micronesia/Africa/Southwest Navajo, etc……..etc…….. 

So gentle and indulgent reader if you made it this far, either I’ve entertained you ……. or like too many in health care, you have OCD. Lets both take a rest……. or in my case, to quote Winston Churchill….. a Change is as good as a rest….. and since at my age I am governed very much by the law of Weird Al Yankovic ….. I’ll be mellow when I am dead….. I prefer a change to a rest… the great rest will come entirely before I am ready for it……. 

Merry Xmas, You’all from this little coroner (that appears to be a Freudian Slip-Not there don’t you think? But that is another story for another day) …. correction from this little corner of cyberSpace, I wish you a happy set of holidays of your choice..... a shame, the one thing and truest thing time has taught me, with enough elemental and abundant natural ignorance you can spend a lifetime never knowing enough…… and I prove that too me every day, and I am grateful for all I have learned in the past year and hopefully I have shared something of value to you all as well.

Merry Xmas, Happy Hanukkah, Joyous Kwanzaa, keep BOXING day, eh! , or Shab-e Yalda……….   etc, etc, etc…… 


Can’t leave without telling the second best joke I know……. but, I spoil the fun, by reminding the gentle reader of the point that Duke Ellington’s Theme Song was the Billy Strayhorn Classic  ’Take the A-Train’…… so, what is the first song every Canadian Jazz Musician Learns to Play?……. Take the Train, eh!  heheheheehehhheeeeehhhheeee …….    

Tuesday, July 28, 2015

Hospital Noel

The walls of this place never change. And time and season are abridged and Null.

The hospital stands mute witness to birthing and dying. A temple in my younger days, now an environmentally correct factory.

I didn't use to begrudge my years passing, while passing through these halls, and hardly seemed to notice that one more Christmas was spent, in the pursuit of the affection and gratituide of strangers.

This Christmas seems distant for this. Perhaps it is the distance of being Attending not house officer, Supervisor rather than Actor in this ancient play.

Other years I spent mercenary in foreign ER's working to pay for the education of my son whose mind like my own fails to suit the majority.

This year, the 'Unit' is relatively quiet, and with the passing of the years, Familiarity my old enemy, my old Bane, the ennui of competence overwhelms me.

No excitement of newness, no being on the knife's edge of my abilities can drive me now.

Only left are the faces of my children in their Childhood, now taken from me with times swift and merciless passing, vapors on the wind that sweeps desolately through me, and with Scrooge-like remorse I see Christmas as it should have been, with my children.

I listen as I write, to the lyrical elegance of a Medieval Mystic, the voices resound through my own soul, and recall as time when I too served in a Monastery, served gladly as a way to escape my own putrid and flawed humanity.

But as the dust has blown he who has created that which outlived him, I now stand scoured by that time dust, raw and saddened at the death of Childhood.

Death I know well, Memories I am master of, Words serve me gladly, but hot, sour, and bitterly galling is this life spent in excess passion for the never granted Love of strangers

I mourn appropriate to the Solstice, Appropriate to the winters cold and darkest days.

I mourn the death of my children's Childs years, the end of passion for Craft, The death of Medievalism, and the passing of my Guild into industrial irrelevance.

I await now, hoping that as the days complete another cyclical year, that the promise of the mystic will be fulfilled: New Life, New Purpose, New Goals, Newness, Rebirth The light and Joy of Spring.

And I hope I will recapture in my children's children, the children I left each Christmas for service in these hollow and false temples.

frank meissner md
25 Dec 1995

Thursday, January 29, 2015

Making a MOC-kery of Medical Professionalism

A recent war has erupted between physicians and speciality certification organizations, particularly the American Board of Internal Medicine. This revolt has been lead by in particular several impassioned cardiologists in response to the so-called maintenance of certification (MOC) requirements now being levied upon physicians in order to return their status as ‘board certified’ physicians. Board certification is increasingly a necessary requirement for any physician who desires to practice in areas that are considered financially or geographically advantageous. As such, ‘passing the boards’ is the obsession of most house officers and subspecialty fellows I have ever trained. Ironically, most physicians I have known who ‘failed the boards’ are generally poor test takers, or more accurately anxious test takers, rather than those who lack the knowledge to pass the boards. That is not too say that the initial examinations are not in themselves a useful exercise early in ones career. 

However, most board certification organizations now limit their certifications to a somewhat arbitrary term limit of 10 years. Once past that time frame, recertification examination is the norm and increasingly in addition to the certification test, additional work is required to qualify yourself to sit for the board examination. These additional requirements are referred to as Maintenance of Certification activities, which generally require outside study and additional test taking prior to the board examinations. 

A fire storm has erupted in the rank and file of the physician work force particularly the cardiology work force concerning MOC requirements in general and even the requirement for board recertification in particular. Physician complaints are centered around the costs of the process, both in dollars and time commitments, the perceived irrelevance of in particular the MOC activities, disputes over the credentialing bodies assertion that these activities or examinations verify clinical expertise or ensure that the physician is keeping ‘up’ with developments in their respective fields. 

A principle driver for the controversy seems to be in particular the diminishing time horizons for non-academic practicing physicians, by this I mean that wide scale use of EMR technologies have resulted in several hours per day being added to that day in order to document care activities. Additionally, increasing regulatory and statutory requirements also eat away at the practice day adding what is usually considered non-value added tasks to the clinicians work day. Furthermore, as many have argued, the recertification processes are considered extremely expensive and the output of the process considered by many to be irrelevant. Furthermore, bitterness about one more set of agents who demand gold for their services when the value of those services are contentious and debatable. 

Personally, I believe it is naive and virtually delusional to believe that an examination occurring every 10 years makes any contribution in a practical way to ‘keeping up’ with current practice and technical innovations.   

I will use my own professional experiences as an example to illustrate the dimensions of the debate. I completed cardiology fellowship training in 1991, and was a product of a three year fellowship interval, which in the year of my graduation from fellowship was made mandatory from 2 years to three years of training. Current fellowship training is now four years in duration, with an additional 1-2 years added on if you wish to sub specialize in interventional, Electrophysiology, diagnostic imaging (MRI/CT Angiography/Nuclear Cardiology/Echocardidiography), or Advanced Heart Failure and Transplantation). 

At the time of my fellowship training, EP and Interventional Fellowships were just being established. As a fellow, I was trained in non-dynamic SPECT thallium imaging for ischemia scanning and Tc-99m labeled MUGA scanning for LV function assessment as nuclear cardiology techniques. Echo techniques included m-Mode, 2D, pulse wave and continuous wave Doppler, and the hot new thing, color flow Doppler imaging. I was the 2nd Cardiologist in the USAF to be specifically trained in transesophageal echocardiography. IV thrombolysis had just evolved into the standard of practice for acute MI therapy. Diagnostic catheterization was done by brachial artery cutdown or femoral artery access using 7 or 8-French sheaths with manual hold procedures. Dual chamber percutaneous programmable pacemakers were widely implanted but ICD implantation required thoracotomy placement of epicardial patches, and implantation of the defibrillator generator in the subcutaneous tissues of the abdomen with tunneling to the previously placed epicardial leads.The defibrillator had no pacing functionality and if pacing was required a separate pacemaker had to be implanted at the time of that implantation. I was not trained in pacemaker implantation as a fellow. Peripheral angiography and the rudimentary interventions of the time were done exclusively by interventional radiologists. Coronary interventions were limited to proximal lesions of single vessels treated with on the wire balloon systems or over the wire balloon systems that were not rapidly exchangeable and which required two physician operators to effectively utilize the balloon dilatation systems. Complications of angioplasty balloon only procedures were reasonably frequent and ‘bailout’ for complications usually lead to emergency coronary bypass surgical procedures. Post PTCA anticoagulation strategies were limited to heparin and coumadin. Coronary artery non-invasive imaging was limited to dedicated cardiac only high energy tomographic x-ray systems utilizing mono-energetic focused beam x-ray tomographic imaging techniques. Mechanical assist devices were limited to the intra-aprtoc balloon pump. 

I recently sat for and passed my third cardiology board examination. Over the course of my 20(+) career as a cardiologist technical progress has been mind blowing.

I now use Nuclear imaging techniques that include dynamic assessment of LV systolic function, enhanced tracers that greatly improve image quality over the older Thallium image techniques, advanced computer work stations that facilitate on the fly analysis of the images, and I have passed and re-passed a dedicated certification board in Nuclear Cardiology which is now required by many private payers in order for me to bill for these interpretations. I have recertification of this board examination above and beyond the cardiology board examination looming in front of me in 2018. 

I implant pacers, bi-ventricular lead pacing and defibrillator systems as well as subcutaneous defibrillators. In order to do so, I underwent rigorous self study, tutorial and proctored clinical experiences in implantation techniques as well as dedicated CME training in ICD implantation and follow up as well as becoming formally tested for expertise in device implantation and follow up by a certification board that will mandate a re-certification evaluation in 10 years from initial certification. 

I was not doing interventional cardiology for several years after fellowship training, so that when I once again practiced in a community in which interventional procedures were done, I underwent proctored training by my partner in modern stenting procedures as well as intense self study and CME based education in interventional cardiology and peripheral interventional cardiology. As of now, neither my partner nor myself do valve replacement by catheter or catheter based mitral valve repair, but we still need to understand these techniques in order to appropriately select patients for referral for these procedures. Within the cath laboratory, I now do radial artery angiography as well as trans-femoral angiography and routinely utilize femoral closure devices that have dramatically reduced the incidence of femoral arterial complications and results in mobilization and discharge of the patient post procedure within 4 hours of that procedure. 

Instead of spending 5-10 days in the hospital after their MI, my patient’s now meet me in the ED are taken urgently to the cath lab, routinely have the ST elevation MI aborted by direct percutaneous interventions within the 90 minute time frame felt essential to good outcomes and routinely leave the hospital the day after their aborted infarction. Peripheral angiography procedures include intra-arterial and venous interventions designed for severe claudication and limb salvage procedures as well as advanced catheter based therapies for treatment of severe occlusive DVT and acute catheter based pulmonary embolism therapies.   

Echocardiography techniques have expanded explosively since my fellowship training, and I now interpret echocardiograms utilizing strain analysis, real time 3-D techniques, and my TEE systems have evolved from monoplane imaging to real time 3D systems. And yes, in order to certify our practices echocardiography laboratory I had to become boarded in echocardiography by yet a different certification board. 

Additionally, what used to take a $250.000 echocardiography system in order to generate 2D/ color Doppler images can now be done with a hand held ultrasound system costing < $10,000, without involvement of another technical resource (U/S technician). In addition to superb cardiovascular imaging, this system does chest/abdominal), Ob-GYN imaging as well as 2D/Color Flow vascular imaging. This revolution in providing immediate U/S imaging at the point of care, means that as a cardiologist, critical care physician, and Emergency Medicine physician I can answer clinical questions with the initial evaluation of the patient that previously took valuable minutes or hours to answer. And if those questions have life threatening dimensions, such as an acute pulmonary embolism, I can save valuable minutes and hours in diagnosis and institute effective therapy literally at the point of initial evaluation of the patient.  So important is this capability that I have also trained and subsequently certified as both a general and cardiac specific ultrasonography technician. 

Over a 3 year time frame, I intensively trained myself again through self-study, CME based education, and very expensive and intensive focused work shops in CT cardiac computed tomography, so that I can offer my patient’s non-invasive high resolution coronary, carotid, and peripheral angiography when this is a reasonable alternative to invasive angiography. Once again, demonstration of this expertise requires yet another certification board testifying to my expertise in this area. 

My partner and I have embarked on a program to provide advanced heart failure technologies for our patient’s above and beyond Bi-V pacing therapies and are starting to manage LV assist devices as destination and bridge to transplant therapies in our metropolitan area. This also entails specialized self directed and proctored learning and ultimately another board certification process. 

The point of this tedious discussion is that these advances have been made, and as a matter of professional growth and expertise, I have had to continuously expand and refine my own cardiology diagnostic and therapeutic tool kit. All this has been done in spite of rather than as a requirements for cardiology board recertification not because of them. It is in the context of this overwhelming personal commitment in time, energy, and cash outlay that the debate about board recertification turns. 

From the context of taking the cardiology boards three times, I can’t say that study for them were helpful in coming to grips with the specialized knowledge required to support my current clinical practice of cardiology. Never mind the fact that as someone also board certified in critical care medicine, that this field also has demonstrated an explosive growth in techniques and knowledge that also requires intense time commitment.  

A much more important factor for helping me keep up with the brisk rate of change of biomedical knowledge and techniques is real time access to the internet and the plethora of medical resources found their. Prior to wide scale access to internet resources, I used to always have multiple reference CD’s, now obsolete since I can access literally any relevant medical information resource with a laptop, tablet, or smart phone. 

So, in summary, I agree with my colleagues who feel that MOC activities demonstrate no value with respect to staying abreast of new techniques and therapies, and in fact detract from this knowledge acquisition, as time is a zero sum game, and no one other than yourself understands what contributes to your practice. The most important lesson, spoken by someone who stopped going to classes after my first 6 wk test in medical school, is learning how to learn, i.e., how to learn on your own in response to your own goals and learning needs and the needs of your local medical practice and needs most importantly of your patient population.     

Tuesday, January 13, 2015

The 5 Stages of EMR Acceptance (With Apologies to Kubler-Ross)


                 I can’t believe they are making me use this system!




‘Look if I agree too willingly and cheerfully use this system, can you ask for and fund these change orders, add these features, re-engineer this screen…..blah! blah!  Blah!, etc. '


I can’t beeeelieeeeeeve (sob, sob, sob, sob) theeeey (sob, sob, sob) are making meeeee (pouring tears from both eye tear wells) use this system!’ 


           I believe they are making me use this system.  (Resigned Sigh) 

And just as in the original Kubler-Ross model, our only release from EMR agony is death……. an eventuality that I used to accept stoically as inevitable, but now positively look  forward to its release (as do my carpal-ly tunneled wrists!). 

Over the last months and the last several years as the deployment of EMR systems have proliferated even the most enthusiastic advocates of electronic documentation have difficulty pointing to any compelling advantages of the EMR systems other than enhanced legibility of charting and improved justification for higher billing. 

The costs are enormous for the front line clinician and his patient struggling to connect across the increasing gulf of random bytes and bits that contain the essence of the second oldest 1:1 relationship on the planet. 

It is perhaps the time of life to romanticize the old in preference for the new. But I don't think I really suffer from that illness. However, the thing that attracted many of my colleagues, and certainly myself to medicine was the unparalleled opportunity to be autonomous in a respected profession. 

However, the profession has been under systematic assault from outside and within. Furthermore, for my own part, having spent the vast majority of my time as a physician within the US military I have become totally disenchanted (if I ever was enchanted with ) with medicine for profit.  

As an undergraduate mathematics major with a heavy interest in and emphasis in computation theory during my undergraduate days, I was attracted to the field of medical informatics as a resident, just as I was attracted by the physics and mathematics that underlie most of cardiology.

However, when I learned in my informatics training that 80(+) % of medical costs were driven by physicians decisions, it became axiomatic to me that control of those decisions was a major hidden agenda item in the field. Furthermore, my non-physician informatics mentors, most prominently Reed Gardner failed to ever understand why I would want to look at my own radiological studies since I am not a radiologist, he considered this a waste of energy and effort, and never accepted my own assertion that since I brought the patient to the film, I could (and do) find things in the study either missed or overlooked by my fine radiological colleagues.

For me the allure of this field medical informatics was how to help myself and others make better decisions, not necessarily make standardized decisions. 

I am really un-humble, I am an exceptionally good clinician, but then that is all I have done for an average of 12-16 hours a day, every day for about 32 years (wow has it been that long) if I can't figure out this dance after 80,000 (+) partners I am a slow study.  

To my eye the current quality initiatives are laughable in their simple mindedness. But the reality of statistical control theory, the soft and unpleasant underbelly of the theory is that the highs, i.e., the exceptional as well as the under performer are both squeezed/regressed to the mean. As some one never content to be within the mean, it makes me mean, and unpleasant at times to be forced towards the just barely acceptable. 

And that is how every good doctor is feeling right about now with the drive towards poorly designed encounter capture systems (I won't dignify these monstrous pieces of software by calling them Electronic Medical Records), we are being driven to a pabulum state of consciousness just as our teachers have been driven to teaching the test, we are driven to documentation for billing, not for caring for the patient or for doing an exceptional job clinically. 
If I compare my professional dictations of yesterday, they were elegant, articulate, crafted with the care a good writer exerts over his/her craft;  But using the charge maximization systems now so prevalent, I can examine the chart with a magnifying glass and not find a recognizable part of my patient within the 'sameness' that characterize these infernal charting schemes.

Designed by engineers with the advisement of financial trolls who believe that a complete record is preferable over a patient's story. For those of us who learned to enjoy the patient's story and who are replenished and nourished and enchanted by these tales, there is are no real stories anymore. And the price of this de-emphasis on the unique patient in front of you, is higher medical costs, for the other 80% rule in medicine is 80% of the diagnoses are made by history and careful, intelligent, and active listening. The practice of narrative medicine is in my view, the best way to practice no matter what you practice, but the infernal button pushing, needed to be done to get paid, prevents the elucidation of the story at the center of the symptom and as such, results in good billing, but often times the wrong or incomplete answer.

Especially in my Emergency Department work, much less so in my cardiology practice, the time pressures result in conformity to a standardized and scripted response for the problem at hand since you don't have the time to produce a hand-crafted thoughtful response to the problem at hand. This becomes disheartening to those of us in the profession who were raised to adhere to a standard in which you did your best for everyone, no matter what the odds or inconveniences or personal sacrifices. But this atmosphere/culture of expected exceptionality has been replaced by 'is it enough to guarantee maximum return of billing.'

But at least for me it is the uniformity of the appearance of the products of medical work that is the output of electronic documentation systems that makes it seem like such a soul robbing endeavor. And I believe passionately that true clinical expertise is shown by what you choose to leave out, not put in the story or presentation of the patients case to colleagues.

Again, my goal here is not to be nostalgic for the old but rather to mirror for the fresh and unprejudiced minds in our mists, that the backlash at EMR technologies being seen among my colleagues does not necessarily represent push back from techno-Luddites but rather can be interpreted as a meaningful critique of the inadequacy of the current systems to support the healer and shaman that is the core personality component of every good doctor I have ever met, trained, or practiced with.

Existence of preventable medical errors is a feature of all types of practice, and as we well know, as detailed many times by Scott Silverstein ( (also a negative nelly — but than I think in the field of medical informatics you have the choice of two diametrically opposed roles the negative nelly or the cheerleader)  that those who chant the mantra of patient safety seem perfectly content to minimize, ignore, or down play the new and more difficult to detect and prevent errors attendant to use of medical software systems. Classic example of EMR safety failings was the recent EPIC disaster (pun intended) related to the failure of diagnosis of the 1st case of Ebola virus infection in the US. ( ( "Travel Information Wasn't Communicated In Dallas Ebola Case Due To Electronic Health Record Flaw" (Huffington Post),

As many do not  know, the most costly software on the planet is Space Shuttle code which costs about $100,000 per line of code, and for which the code has meet the most rigorous software engineering tests, i.e., each line is proven by mathematical techniques to be complete, consistent, and free of unexpected/unpredicted program errors. Compare that level of software engineering excellence to software I have personally used where not only are there bug upon bug in the software, but the damn labels on buttons representing symptoms are misspelled. I consider it axiomatic, if the buttons are misspelled the code is flawed, but than you can't judge a book by its cover, or can you? 

Tuesday, April 23, 2013

What The World Needs Now .... is Codes, Sweet Codes, It's The Only Thing Theres Just Too Little Of........

This is without a doubt my favorite ICD-9 codes. Imagine the granularity of clinical description possible with the additional codes that will be found in ICD-10!

""ICD-10-CM codes are the ones designated for use in documenting diagnoses. They are 3-7 characters in length and total 68,000, while ICD-9-CM diagnosis codes are 3-5 digits in length and number over 14,000. The ICD-10-PCS are the procedure codes and they are alphanumeric, 7 characters in length, and total approximately 87,000, while ICD-9-CM procedure codes are only 3-4 numbers in length and total approximately 4,000 codes.""

As it is the numbers and complexity of codes seen with ICD beggars the imagination. Furthermore, the use of those codes is by necessity rudimentary and poorly descriptive of the actual events surrounding the patient's hospital or clinical course. The time pressures of clinical practice often result in the practitioner using the 1st plausable code for the clinical scenario rather than the best or most descriptive for the scenario.

In the final analysis the reality of clinical work is that creating is a more intellectually gratifying and intrinsically more rapid process than choosing. WIth respect to a previous post in which I mentioned the supercomputer Watson, analysis of free text by such an artificial intelligence will come much closer to mirroring the reality of clinical work than trying to train the practitioner in the nuances of translation of clinical thought into structured data. Ultimately as so famously captured in the quote from Alfred Korzybski, 'The Map is not the territory.'