Monday, December 28, 2009

Are Dissmissive Industry and Government Reactions to Physician Concerns about EHR's and other Clinical IT Simply Perverse?

Yes, they are.

At the Nov. 10, 2009 essay "Academic Freedom and ED EHR's Down Under: Another Update and a Welcome Development" and preceding essays linked to it, I wrote about an Australian informatics professor's travails in writing about ED EHR's.

He wrote a mixed-method essay about the mission hostile user experiences ED physicians in NSW reported about the EHR's they were being compelled to use, in addition to similar negative commentary from ED physician experts in other lands. The latest version of the paper "A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck" is here (PDF) or accessible from his department's webpage here.

The government attempted to censor the paper and likely censure the author, and I speculate the HIT industry was not far behind.

Below is an example from my own city on why I found the reactions to the evolving ED EHR paper - reactions that "blamed the doctors" or dismissed what appear to be frequently encountered ED physician concerns - perverse.

I use the term "perverse" in the most formal sense of the word:
Merriam-Webster dictionary:

Perverse (adj).
Etymology: Middle English, from Anglo-French purvers, pervers, from Latin perversus, from past participle of pervertere
Date: 14th century

1 a : turned away from what is right or good : corrupt b : improper, incorrect c : contrary to the evidence or the direction of the judge on a point of law
2 a : obstinate in opposing what is right, reasonable, or accepted : wrongheaded b : arising from or indicative of stubbornness or obstinacy
3 : marked by peevishness or petulance : cranky
4 : marked by perversion : perverted

The very, very last thing patients need is to have ED clinicians slowed down.

Concerns expressed by even a minority of ED physicians that EHR's slow them down or reduce their effectiveness ought to set off alarm bells and rigorous government investigations of the kind that would arise if airline pilots started to complain about lax security allowing passengers on board with bombs:

Dec 24, 2009
Philadelphia Inquirer

Philadelphia ERs seek solutions to crowding

By Marie McCullough

Inquirer Staff Writer

Two of the region's leading medical centers have racked up the city's highest number of "diversions" - periods when ambulances are advised to steer clear because the emergency room is so full.

The Hospital of the University of Pennsylvania and Thomas Jefferson University Hospital are working to reduce such diversions as the number of emergency rooms in the city has continued to fall. This year, Penn has reduced the disruptions by 22 percent and Jefferson by 28 percent.

As they seek solutions, the hospitals are examining their own practices, reflecting a national shift in efforts to address the perennial crisis of ER overcrowding.

Consider Jefferson. This year it reduced diversion hours even though the number of ER patients, the severity of their medical needs, and staffing stayed about the same. Jefferson relieved overcrowding by finding ways to move patients in and out of the ER - and the whole hospital - faster.

"That's where I'm focused, on improving efficiencies," said Rex Mathew, hired by Jefferson two years ago for the new job of vice president of emergency medicine clinical operations.

This is not to suggest that the nation's emergency medical-care system has been slacking. From 1992 to 2002, the number of annual emergency-room visits increased 23 percent, while the number of ERs decreased 15 percent, studies show.

In the Philadelphia region, the contraction has been more dramatic - from 62 ERs in 1993 to 38 now, a 39 percent decrease. The most recent loss was this year's closing of Northeastern Hospital, which had 45,000 emergency visits annually. The impact has been felt at Aria Health-Frankford Campus, where Joaquin Rivera died in the ER while waiting for care on Nov. 28.

While there is no evidence that overcrowding played a role in his death, Frankford had nearly as many diversions in November - 121 hours - as all of last year.

Emergency departments are beset by growing numbers of the uninsured, the chronically ill, and the aged.

Nonetheless, experts say it's time for hospitals to stop blaming ER overcrowding on economic, social, and demographic factors that are beyond their control, and start looking inward. A recent Government Accountability Office report found that even in life-and-death cases, large percentages of ER patients do not see doctors within recommended times.

"Many hospitals have done little to address the patient-flow obstacles that lead to overcrowded" emergency rooms, says a report by Urgent Matters, an ER improvement initiative funded by the Robert Wood Johnson Foundation.

Jefferson and Hahnemann University Hospital are among six U.S. hospitals using grants from Urgent Matters to develop practical strategies for reducing ER crowding. These will be shared nationally through newsletters, the Web, and conferences.

... Most fixes, however, are neither easy nor obvious. Sick patients may lie on gurneys for hours in ERs, uncomfortable and taking up precious space, while they wait for a hospital bed to become available.

... "The problem is not just physical space but effective space," said Robert McNamara, chair of emergency medicine at Temple University Hospital. "With hospital margins tight, there may be beds, but no staff to cover them. And hospitals try to keep staffing tight to keep costs down."

Temple has the city's busiest ER, with 74,000 adult and 20,000 pediatric patients this year - 24 percent of whom were admitted to the hospital, McNamara said. Anticipating a surge in demand following Northeastern's closure, Temple added ER staff and made a concerted effort to speed up testing and discharge procedures, he said.

This year, through November, Temple had 118 hours when ambulances were diverted.

The Hospital of the University of Pennsylvania, with about 60,000 ER patients and a 26 percent admission rate, was by far the city's leading diverter - more than 1,000 hours through November.

... the crowding conundrum continues to evolve. One question is whether health-care reform - which now seems imminent - may increase ER volume rather than reducing it, as millions more Americans become insured.

The situation is actually even worse.

A patient recently died of a heart attack, sitting in the waiting room of a hospital where I once rotated during my internship, Frankford Hospital. He was not found until others in the waiting room stole the dead patient-in-waiting's wristwatch. The man sat unresponsive for nearly an hour in the waiting area of Aria Health Frankford Hospital before a visitor notified security and a doctor arrived.

Dec. 1, 2009

Philadelphia Inquirer

Waiting to be seen at hospital, dying Joaquin Rivera was robbed, police say

... According to Philadelphia police, Rivera walked into Aria Health's Frankford Campus, on Frankford Avenue near Harrison Street, about 10:45 p.m. Saturday.

He was alone, and apparently had walked from his nearby home on Duffield Street near Foulkrod, his son said.

Rivera complained of feeling pain in his left arm and abdomen, and was told to sit in the waiting area, said police spokesman Lt. Frank Vanore. [A middle aged man with left arm and abdominal pain told to 'sit in the waiting room?' One wonders who would qualify for sitting under medical observation - ed.]

At some point during the next hour, Rivera, a longtime bilingual counselor at Olney High School, lost consciousness. He inadvertently became a target, Vanore said, to three other people in the waiting room...

[One of the other people] signed up to be seen by a doctor, while his two cohorts sat near Rivera. "At some point, [one of the people] is observed taking the victim's watch and passing it to the other man," Vanore said.

When a witness ran to notify a security guard of the crime and Rivera's condition, the limping man and his female partner fled, Vanore said. Hospital personnel rushed to Rivera's aid, but it was too late.

He was pronounced dead shortly after midnight Sunday. Vanore said police have not yet learned of Rivera's cause of death.

The family said he was believed to have died of a heart attack.

I reiterate, the very last thing in the world ER clinicians need are ill-conceived and ill-implemented electronic health records systems that slow them down.

Instead of attempted censorship and spin control, such concerns should be addressed throughly, impartially and promptly if not immediately.

What could one call the arrogance or devil-may-care mindset in the government and health IT industry that dismisses such concerns so cavalierly, other than "perverse?"

-- SS

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