Thursday, October 27, 2011

Doctor Placed on Administrative Leave ("Railroaded?") Because He "Fell Behind on Handling Electronic Records For His Patients"

This story is tragic and appalling:

Lincoln doctor, Memorial Health clash over electronic records
The State Journal-Register
Posted Oct 19, 2011 @ 11:00 PM
Last update Oct 20, 2011 @ 06:37 AM

LINCOLN — A Lincoln doctor who was removed from his job a month ago says his bosses in Springfield failed to train him properly on a new electronic medical-records system.
An official with Memorial Health System disputes the doctor’s claims.
Dr. Steven Kottemann, 63, who was placed on paid administrative leave Sept. 16 by Springfield-based Memorial Health System, wants to return to his $100,000-a-year position as a family physician at Family Medical Center of Lincoln, 515 N. College St.
Kotteman said he had “no computer skills” before Memorial turned on an all-electronic medical-records system Jan. 12, and he fell behind on handling electronic records for his patients. He said he was accused by Memorial of creating “a liability for the clinic.”

I think it appropriate to question whether an EHR mission hostile user experience may be creating a liability for the clinic. Also see the semi-rhetorical question-titled White Paper "Do EHR's Increase Liability?" (PDF).

“They did this to me,” Kottemann told The State Journal-Register from his home in Lincoln. “They bought a lousy system. [I would like to know the vendor - ed.] They caused everything, as far as I’m concerned, and I resent the fact that they’re trying to make me look bad.”
Memorial’s chief medical officer, Dr. Rajesh Govindaiah, said Kottemann has been treated fairly. Though Govindaiah wouldn’t go into specifics, he said concerns about Kottemann’s performance go beyond his proficiency with electronic medical records.

Was this Sham Peer Review?

“Dr. Kottemann is aware of the issues,” Govindaiah said. “He knows more than I’m allowed to tell you, and he knows that this is related to more than just the electronic medical record. It has to do with performance and ensuring a safe environment for our patients.”

That sounds like an excuse, considering the patient testimonials in the article and on the linked Facebook page mentioned below.
In the meantime, NIST is just now studying poor health IT usability (see my post "NIST on the EHR Mission Hostile User Experience: Blame the User?", and IOM is just now studying safety of electronic medical records (see my post "Cart before the horse, again: IOM to study HIT patient safety for ONC.")
FDA chimes in that injuries and deaths are reported, but the magnitude is not known; however they won't regulate a technology that is a "political hot potato."
Looking at FDA's MAUDE database on just about the only health IT vendor who reports there (it's voluntary) makes my hair stand on end. See "MAUDE and HIT Risks: What in God's Name is Going on Here?"
Further, the literature is conflicting on benefits of EMR's (see my post "An Updated Reading List on Health IT"). Who, exactly, is promoting patient safety?

Kottemann said Govindaiah’s “vague innuendos” amount to an “administrative snow job.”

"Railroading" seems like a better term.

Patients ask why
Kottemann, who grew up in the Chicago area, moved to Lincoln in 1977. He has practiced in Lincoln his entire career and says he is the oldest practicing physician in the Logan County seat. But he has no plans to retire.
His patients have come to his defense, creating a Facebook page and sending letters to Memorial officials.
“This man is very genuine,” longtime patient and Lincoln resident Jonette Tibbs said. “He is just the greatest. He’s on that upper crust. Why would you like to get rid of a doctor like that?”
Another patient, Fern Donnan of Beason, said Memorial officials should be more understanding.
“Technology is a learning curve, and you need to allow for that and support that,” she said.
Donnan said she and her family members will avoid Memorial health-care providers unless Kottemann is reinstated.
“I don’t know why they’re pushing him out,” she said.

Perhaps because he just won't cave in using the health IT that has been forced upon him, and upon his patients (without their informed consent, I might add). See my post "Draft Patient Rights Statement and Informed Consent on Use of HIT."

It gets worse:

Stroke in 2008
Kottemann said he fell behind because the new system wouldn’t accept his dictated notes after he saw patients in the office.
The system’s computers were supposed to accept dictation, he said. But he said he learned after several weeks that the system was mistakenly deleting dictations.
[See Informatics expert Dr. Jon Patrick's forensic analysis of a major EHR system, especially part 7 "The Integrated Assessment" for why that might be so - ed.]
He said he told his supervisors about the problem, but when there was no response [because it's the user's fault - ed.], he was faced with the other main option — typing notes into the system while he sat with patients in exam rooms.
A minor stroke in 2008 makes it hard for Kottemann to write or type for sustained periods of time. He also believed that typing would detract from his communication with patients. [It often does, even for good typists. See my later link to a post on Scribes - ed.]

It sounds like there may be a disability lawsuit as well as a sham peer review lawsuit brewing here...

As a result, he decided not to attempt to type during patient visits. With dictation not an option, Kottemann for several months would go to the office before regular business hours and stay after the office closed in order to type in his notes.

“It got to the point where I was going in seven days a week to keep up,” he said.

The doctor was serving the computer; it became his master.

Memorial sookesman Michael Leathers said no other doctor in the Lincoln clinic who used the new system’s dictation option lost any dictations.
Kottemann said a Memorial official put him on administrative leave without warning last month.
Govindaiah, however, said Memorial officials were working with Kottemann “to address some performance concerns … well in advance of Sept. 16.”
Govindaiah said “mutually agreed-upon targets for performance” weren’t being met. Memorial placed Kottemann on a “paid leave of absence in order to address our concerns and to identify why we weren’t making any progress,” Govindaiah said.

Again, was this sham peer review, or was full and fair due process being followed?

At an impasse
Kottemann said he knows his slowness on the system eventually could have compromised the care of his patients, but he wouldn’t have gotten behind if he had been better trained and if the dictation system had worked.

It is well known that hospitals skimp on training.
Govindaiah said Memorial did provide additional training and scribes to help him keep up.
But Kottemann said the scribes lacked medical knowledge, so he couldn’t rely on them.

Indeed. See my post "The Ultimate Workaround To Mission Hostile Health IT: Humans (a.k.a. "Scribes").

After being put on leave, Kottemann said he was cleared to return to work by a Bloomington psychologist and a Springfield occupational-medicine specialist. Those evaluations were requested by Memorial, he said.
After those evaluations, Kottemann said Memorial also wanted him checked out by a neuropsychologist. Kottemann said he has refused this evaluation because he now believes Memorial officials are trying to have him declared impaired so they can fire him.

Could this be a case of constructive discharge as well?

Kottemann said he scored among the top 1 percent of family medicine specialists in the 2009 exam he took to renew his board certification.

But, the computer doesn't like him, so out he goes?
... Kottemann said he doesn’t know what will happen next, but he has secured legal representation when dealing with Memorial in the future.
“I want to see my patients, and they want to see me,” he said.

But the computer doesn't want to see you. You're just not adapting to its deficiencies properly.
Here's a passage that is really stunning:

Doctors need to adapt, Medical Society president says
Electronic medical-record systems aren’t perfect, and questions about whether they improve patient care and save money haven’t been answered conclusively, but doctors must try to adapt to the systems, the president of the Illinois State Medical Society says.
“This is going to be the future, and we need to work on that,” said Dr. Wayne Polek, 57, an anesthesiologist who practices in the Chicago suburb of Geneva. “Like any technology, it has a lot of promise, but the devil’s in the details.”

IT designers and implementers need to first adapt to doctors, not the other way around, I say to the Medical Society President. And it's OK for technology to be bedeviled by details...when the subjects are lab rats, not unconsenting human subjects, I say to the anesthesiologist. Hospitals are not IT beta testing and development shops.

Doctors’ everyday use of electronic records is important for clinics and hospitals to qualify for millions of dollars in federal incentive payments and to avoid financial penalties in the future. But Polek said it shouldn’t be surprising that some doctors find the transition difficult.

This is an experimental technology.

Let me repeat:


Perhaps Polek should read what the major trade organization for HIT, HIMSS, and the National Research Council say. From my post "Unintended errors with EHR-based result management: a case series, and a special pleading for health IT":

HIMSS's former Chairman of the Board admits the technology remains experimental:
... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better;
While HIMSS itself admits in this 2009 PDF that
"Electronic medical record (EMR) adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available";
While the National Research Council (the highest scientific authority in the U.S.) in 2009 reported that:
"Current Approaches to U.S. Health Care Information Technology are Insufficient" and that the technology "does not support clinicians' cognitive needs." The study was chaired by Medical Informatics pioneers Octo Barnett (Harvard/MGH) and William Stead (Vanderbilt).

EHR's also may facilitate record spoliation and make upcoding/overbilling easier. See my post "Does EHR-Incited Upcoding (Also Known as "Fraud") Need Investigation by CMS, And Could it Explain HIT Irrational Exuberance?" on the latter.

“A lot of us, even if we’re doctors, have problems programming a VCR,” he said.

Perhaps the user experience of the VCR, like that of many EHR's, CPOE's etc., is mission hostile.

‘Not so hard’
Dr. Gayle Woodson, 61, a surgeon who is president of the Sangamon County Medical Society, said she is convinced electronic records can improve patient care by making information more accessibly and, in some cases, helping physicians avoid errors.

And what about the errors they promote?

“It’s always a pain to do something different, but it’s not so hard,” she said.

Really? How is that you speak for everyone regarding use of clinical IT and the cognitive issues, distractions, and difficulties it creates for many? E.g., see my post "An Honest Physician Survey on EHR's."

Springfield Clinic deploys a group of nurses specializing in “clinical informatics” who help doctors with the clinic’s electronic record system, chief clinical officer Mary Stewart said.

What is their formal training in the field? Why no physicians specializing in Medical Informatics, such as those postdoctorally trained in the field? Too expensive, perhaps? See my post "ONC Defines a Taxonomy of Robust Healthcare IT Leadership."

Hospital Sisters Health System, which operates St. John’s Hospital, finds that some doctors have more difficulty than others in the transition to electronic records, spokesman Brian Reardon said.
“Doctors who are older need more attention,” Reardon said.

Welcome to the legions of the Masters of the Obvious. - Or, have EHR's become a form of medical age discrimination, to root out those "old docs" who adhere to all those quaint relics of yesteryear (such as the Hippocratic Oath)?

I believe Dr. Kotteman should defend himself vigorously on the issues I bring forth in this post. He should also demand data on near misses, patient injuries, and even patient deaths caused by the EMR he is being coerced to use, whether within his center or at other customer sites.

Let the IT adapt to the doctors, and let the patients consent to its use in their care after being made fully aware of the downsides (as at my reading list).

-- SS


Anonymous said...

Sham peer review at its finest.

He probably complained to the vendor about the defects and flaws in the EMR. Retaliation follows on order of the vendor in keeping with the gag clauses in the contracts.

You asked which EMR is used at Memorial Health System.

From the job listings and the dates at this link, one can reasonably assume it is Cerner.

Live IT or live with IT said...

"Electronic medical-record systems aren’t perfect, and questions about whether they improve patient care and save money haven’t been answered conclusively, but doctors must try to adapt to the systems, the president of the Illinois State Medical Society says."

This is astounding hubris.

Anonymous said...

"IT designers and implementers need to first adapt to doctors, not the other way around,"


InformaticsMD said...

Live IT or live with IT said...

"Electronic medical-record systems aren’t perfect, and questions about whether they improve patient care and save money haven’t been answered conclusively, but doctors must try to adapt to the systems, the president of the Illinois State Medical Society says."

This is astounding hubris.

(The president of the medical society must know the technology also introduces risk.)

You're being polite.

I won't be so polite.

That position is reckless, cavalier, imprudent, irresponsible, and probably represents a breach of the fiduciary responsibilities of the role to patients and physicians.

-- SS