Held Hostage To Health IT? Here Is What Physicians Have To Put Up With Instead Of The Paper Chart...

I might have titled this post "Transforming simplicity in medicine into complexity." It's a wonder clinicians can get clinical work done at all any more.

The following material makes the reports of poor alignment of EHR's to clinical needs, clinician distraction, and the slowing of clinician productivity more understandable by laypeople.

The following are PDF's from a real healthcare organization, publicly accessible (at present), some with actual screen shots of the applications.

How about a 90-page guide simply for entering orders, incidentally grossly mislabeled as "Medical Informatics Physician Education Program" instead of "CPOE application training program" suggesting the authors do not know what Medical Informatics actually is - and also labeled as "Session 1":

• Managing Patient Care Using CPOE (1.2MB PDF)

Here's what it takes to simply discharge a patient:

• House Wide Discharge (Depart Process) training manual (1 MB PDF) - 30 page training manual
  

"Depart Process" is apparently a new buzzword. (Borrowed from the airline industry?) In the B.C. era (before computers), discharge required no 30 page training manual.

I find the introduction to the 30 page "Depart Process Training Manual" interesting:

Good News! The discharge process has been revised and will be a smoother, less complex process for all. The new process will be to use the House Wide Discharge (HWD) Process, (Depart) when discharging your inpatients.

"Less" complex? One can imagine what the "Depart Process" was like before this 30 page training manual.

Here's what it takes to enter or review a note:

• Electronic Documentation –Clinical Notes (12 MB PDF)

Holy complexity, Batman! Entering a clinical note used to involve opening a chart and applying pen to the right paper.

Here is what medical professionals have to contend with when even a minor change is made:

• Tab Changes in the Power Chart (150kb PDF)

Here's what happens if physicians don't complete their H&P's in 24 hours with the EHR system:

• Suspension (31kb PDF)

I especially find the introduction to this "H&P suspension" letter of interest:

You may remember earlier this year when we started immediate suspensions for H&Ps missing at 24 hours as outlined in our Rules and Regulations. Many of you were caught off guard by this and resented being called after you had already missed the deadline and were suspended [I'll bet - ed.].

We certainly heard your complaints [doctors are simply "complainers" - ed.] and stopped the immediate suspensions until we could create a better process. Since then we have been working on ways to achieve the goal of 100% H&Ps present within 24 hours. We have met repeatedly and received recommendations from HIM [Health Information Management a.k.a. Medical Records - ed.] directors, administration, and senior medical staff leaders. Final proposals have been approved by the Medical Executive Committee and are presented to you here.

Beginning January 4, 2010, we will again begin suspending at 24 hours if an H&P is not available on the chart. The stopwatch will start at the time of the admit order. We will make every ["every?" - ed.] effort to contact the physician as the 24 hour deadline grows near. For the few physicians who have had multiple late H&Ps this past year, you will be contacted separately and required to formulate an action plan to present to administration and senior leadership.

Repeatedly late H&Ps will trigger recommendation for a shortened reappointment. Additional measures have been proposed by senior leadership for adoption, if necessary. These include limiting service sizes, stopping all admissions for suspended physicians (not just elective admits) or required use of a nurse practitioner (for a charge) to complete the H&P. [In fact, perhaps physicians should be charging hospitals for their time in being forced to use IT such as this - ed.]

Mussolini could not have done better in getting the trains out on time. At least trains were not experimental technology. (I'd thought it was deplorable as an internal medicine intern in the early 1980's at the now-defunct Hospital of the Medical College of Pennsylvania when our penurious paychecks of about $300 per week were merely withheld if we had not completed our discharge summaries.)

I've commented in the past that physicians and other clinicians are now held hostage to needlessly complex and difficult to use health IT (see my eight part series on the HIT mission hostile user experience here). I don't see anything here to make me change my mind.

Needless to say, being a Medical Informaticist I am not against health IT: I am pro-health IT.

What I do oppose is bad health IT - ill conceived, poorly implemented, mission hostile HIT designed with little thought to, or willful ignorance of, real world side effects in the clinic, office and subspecialty area.

Health IT can be designed to be far better than most commercial HIT from major vendors is now, of which the above links show but one example. This requires, however, that HIT be viewed not as computer projects that involve clinicians, but as medical projects that involve computers.

From that view flows the need for a major shift in HIT power structures and an educational and certification process for IT personnel (such as recommended by the ONC director Dr. Blumenthal that I highlighted in the post "ONC Defines a Taxonomy of Robust Healthcare IT Leadership").

For sake of comparison, from the same hospital system as above, here's what physicians must go through to be found competent:

• Privilege Criteria Grid (120kb PDF)

Here's what IT personnel must currently go through to earn the privilege of designing the tools clinicians must use, and of working in healthcare settings:

The same symbol applies to oversight of such tools themselves by accepted biomedical regulators such as FDA who regulate drugs and tangible medical devices. As I have written before, HIT is a virtual medical device, but a medical device nonetheless. It is a device that by the admissions of its own producers is entirely capable of effecting major impacts on and alterations to clinical care, although the makers rarely admit to adverse impacts.

These discrepancies are astonishing.

-- SS