Transparency International Asks Health Care Professionals About Health Care Corruption

Transparency International, the global NGO that studies and fights corruption, seeks information from health care professionals about health care corruption.  The details are in the official announcement below.  If you are a health care professional, please consider responding to this survey. 

Invitation to participate in a corruption in healthcare survey
Transparency International’s health programme has commenced a new research project to identify the major types of corruption in the health sector. We feel that this research piece will contribute to understanding the corruption vulnerabilities in the health sector and ultimately improve the availability and use of health information to hold governments accountable.

This will feed into the World Health Summit in October, where Transparency International has been invited to run the opening session. We'll also be displaying results from the research on our website and will feature interviews with people about their experiences.

As part of our research, we're keen to hear from as many healthcare professionals as possible. This is to enable us to hear about your experiences of corruption and what you consider corruption to be.

At this stage, we do not want to influence your thoughts - more capture them. A survey has gone online and we would be grateful if you could fill it in and distribute to your peers. 

The survey contains ten questions and can be completed in ten minutes. The survey will run until the end of September.

Given the sensitivity of the subject, the survey is anonymous unless you would like to talk to someone about your experience. At the end of the survey there is an option to leave your contact details.

We're looking forward to hearing your thoughts.

Best wishes,

Michael

Michael Petkov
Programme Officer
Pharmaceuticals & Healthcare Programme
Transparency International UK
michael dot petkov at transparency dot org dot uk

The link to the survey is here.

Say It Ain't So, Again - a "Push Poll" to Minimize the Hazards of Conflicts of Interest ...in the New England Journal of Medicine?

The New England Journal of Medicine recently published a remarkable series of apologiae for conflicts of interest,(1-4) about which we have published three posts, here, here, and here.  Just to ice the cake, the NEJM also set up a reader poll on the subject. Its introduction stated,

we invite you to put yourself in the role of editor and help us decide about the suitability of three hypothetical potential authors of review articles for the Journal.

However, as noted first in a post on the HealthNewsReview.org blog, the poll had a curious design. 

Each of the three hypothetical experts has some type of financial arrangement with the pharmaceutical industry – either royalty payments, speaking fees, or commercially supported research at a university that covers everything except the researcher’s salary.

Noticeably absent was a 'Case #4' describing a potential author with no conflict of interest. 

IMHO, this seems like a biased survey design.  By failing to incorporate a questions about an unconflicted author, the numeric results of the poll could not show whether those answering it would actually favor authors without conflicts of interest.  Of course, the whole thrust of the three commentary(2-4) plus one editorial(1) NEJM series was that concerns about such conflicts are overblown.

Nonetheless, the poll allowed for comments, and as the blog post showed, this bias did not escape notice.  One commentator, Dr David Newman, wrote

The only reason to choose any of the individuals in these cases would be if there were no available alternatives.

This survey bias did not escape Dr Josh Farkas, who wrote this in a PulmCrit blog post,

Perhaps the most interesting component of the media campaign is the reader poll about the adequacy of various hypothetical authors for a review article.  Three potential authors are described, all of whom have significant COIs.  The design of this poll itself is biased, by presenting no authors without COIs.  A more transparent approach might be to simply ask readers 'do you think review article authors should be allowed to have COIs?'

Thus, the NEJM conflict of interest poll appears to be not an attempt at unbiased data collection, but a "push poll."  A "push poll," per Wikipedia, is:

an interactive marketing technique, most commonly employed during political campaigning, in which an individual or organization attempts to influence or alter the view of voters under the guise of conducting a poll.

By prominently publishing a poll with such a biased design, the NEJM has further supported my argument that its current editors are engaging in polemics rather than scholarly debate about the very important issue of conflicts of interest in medicine and health care.  Perhaps the current NEJM editors should consider joining the blogsphere in which polemics abound, while leaving the serious business of scholarly journal editing to those who are more dispassionate.   

References
1.Drazen JM.  Revisiting the commercial-academic interface.  N Eng J Med 2015; ; 372:1853-1854. Link here.
2. Rosenbaum L.  Reconnecting the dots - reinterpreting industry-physician relations.  N Eng J Med 2015; 372:1860-1864.  Link here.
3. Rosenbaum L. Understanding bias - the case for careful study.  N Engl J Med 2015;  372:1959-1963.  Link here.
4.  Rosenbaum L.  Beyond moral outrage - weighing the trade-offs of COI regulation. N Engl J Med 2015; 372: 2064-2068.  Link here.

"EHRs: The Real Story" - Sobering assessment from Medical Economics

From Medical Economics -

"EHRs: The Real Story",  pg. 18-27, Feb. 10, 2014, available here (PDF).

Full issue at http://medicaleconomics.modernmedicine.com/sites/default/files/images/MedicalEconomics/DigitalEdition/Medical-Economics-February-10-2014.pdf - it is large, 12 MB:

... "Despite the government’s bribe of nearly $27 billion to digitize patient records, nearly 70% of physicians say electronic health record (EHR) systems have not been worth it. It’s a sobering statistic backed by newly released data from marketing and research f rm MPI Group and Medical Economics that suggest nearly two-thirds of doctors would not purchase their current EHR system again because of poor functionality and high costs."

Here are other key findings from this national survey:

• 73% of the largest practices would not purchase their current EHR system. The data show that 66% of internal medicine specialists would not purchase their current system. About 60% of respondents in family medicine would also make another EHR choice.

• 67% of physicians dislike the functionality of their EHR systems.

• Nearly half of physicians believe the cost of these systems is too high.

• 45% of respondents say patient care is worse since implementing an EHR. Nearly 23% of internists say patient care is significantly worse.

• 65% of respondents say their EHR systems result in financial losses for the practice. About 43% of internists and other specialists/subspecialists outside of primary care characterized the losses as signifcant.

• About 69% of respondents said that coordination of care with hospitals has not improved.

• Nearly 38% of respondents doubt their system will be viable in five years.

• 74% of respondents believe their vendors will be in business over the next 5 years.

My own views are:

While some might dismiss such surveys as well as reports of harms as "anecdotes" (those same persons conflating scientific discovery with risk management, see http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html), I observe that such articles/surveys are increasing in frequency the past few years and are coming from reasonably capable observers - clinicians - .unlike, say, a Fox News survey of pedestrians on complex political matters.

Another physician survey is here:  http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html.

Here's an interesting ad hoc survey of nurses:  http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html.
.
This is not what the Medical Informatics pioneers intended, and is not due to physicians being Luddites (a topic I addressed at http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html).

In my opinion, organizations that have the expertise to change the current trajectory of this technology such as the American Medical Informatics Association (AMIA) needs to leave its tweed-jacket academic comfort zone and become more proactive - or perhaps I should say aggressive - in combating the industry status quo.  

The health IT industry trade associations such as HIMSS have no such qualms about aggressively and shamelessly pushing their version of EHR utopia, an agenda that has led to massive profits for the industry... but to clinician survey results such as above.  And to injured and dead patients.

-- SS

63% of Physicians are "Very Enthusiastic" about "Limiting Corporate Influence on Physician Behavior," but Will Anyone Notice?

On Health Care Renewal, we have noted how the direct care of patients in the US is increasingly in the hands of large corporations, often for-profit.  We have noted the plight of the corporate physicians who swore oaths to put patients first, and now report to managers who put revenue first.

Health Care Renewal was hardly the first to raise these issues.  For years, the renowned editor emeritus of the New England Journal, Dr Arnold Relman, has been warning about the effects of the commercial practice of medicine, which once was illegal in most US states, and until 1980 was condemned by the American Medical Association (look here).

Yet in a world in which market fundamentalism (or economism, or neoliberalism) is increasingly dominant, there is little room for the view that turning health care into a business, and having the new health care businesses lead by people who are only interested in increasing short term revenue (financialization) and increasing their own compensation might be bad for patients' and the public's health.

However, close reading of a recent article suggests that many physicians "get" this problem, although may be reticent about protesting it.  

Summary of the JAMA Article

Tilburt et al authored an article published in July, 2013 that focused on physicians views about "controlling health care costs."(1)  They sent a survey to 3900 randomly chosen physicians less than 65 years old and in active practice.  2556 (65%) responded.

The survey included questions about who should be responsible for reducing health care costs, and about the physicians' enthusiasm for various means of cutting costs.  The results that got the most publicity were that physicians thought others (trial lawyers, health insurance companies, pharmaceutical and device manufacturers, hospitals and health care systems, patients, and government) were more responsible for controlling costs than physicians. 

Nonetheless, the physicians were relatively enthusiastic about potential cost control measures that would improve "quality and efficiency of care," for example, promoting 75% were very enthusiastic about continuity of care, 69% about promoting chronic disease care coordination, and  70% about "rooting out fraud and abuse."  They were also relatively enthused about "improving conditions for evidence-based decisions," for example, 51% were very enthusiastic about "expanding access to quality and safety data," and and 50% about "promoting head-to-head trials of competing treatments" (also known as a type of comparative effectiveness research).

Strikingly, however, 63% of physicians were "very enthusiastic" about "limiting corporate influence on physician behavior."  The article did not further explain that item.

An Almost Unnoticed Result

The article's results section noted "some or strong enthusiasm for improving conditions for evidence-based decisions," including "limiting corporate influence on physician behavior." It included no further comments on this issue.

The public discussion it generated largely ignored physicians' views on corporate influence..

An accompanying editorial by Dr Ezekiel Emanuel and Mr Andrew Steinmetz (2) called the survey's findings "discouraging" and chided physicians for not having an "all hands on deck" approach to controlling health care costs, stating they "must lead" on this issue, because they "captains of the ship."   It ignored the notion that the physicians may have  thought that their first responsibility was to "individual patients best interests," and thus controlling costs (especially costs that do not accrue directly to patients) should be a secondary concern.  It also belittled their enthusiasm about curbing "fraud and abuse," implying that it was "sufficiently vague" that it "may offer only modest improvements but certainly will not transform the health care system."   Instead, Emanuel and Steinmetz wanted physicians to support six strategies for transforming health care delivery, without citing evidence in support of these strategies.  The Emanuel and Steinmetz editorial ignored the physicians' views on corporate influence.


A post on the In My Humble Opinion blog by Dr Jordan Grumet in turn wondered why physicians should support "Ezekiel's fantasies about healthcare [which] are unsubstantiated."  Dr Grumet decried how particularly primary care physicians have been marginalized, and suggested that if Emanuel and Steinmetz want physicians to act like the captains of the ship they perhaps should not dictate their navigation.  But Dr Grumet apparently did not notice that physicians may realize that their captaincy has been challenged by corporate influence.  .   

Media coverage in, for example, the Los Angeles Times, Fox News, and the Pioneer Press focused on the question of whether physicians were denying a responsibility to control costs, and whether that responsibility was really theirs.  It did not comment on the issue of corporate influence.

However, so far the striking result that a large, well conducted survey showed that the majority of physicians support limiting corporate influence on their behavior remains almost completely unnoticed. 

Summary

We now have some reasonably good data suggesting that the majority of physicians are very troubled by "corporate influences" on them.

It could be that they are troubled by the most direct corporate influences, the practice of medicine by physicians who are employees of corporations, often large, and for-profit.

Dr Arnold Relman reminded us that physicians used to shun the commercial practice of medicine (look here).  Yet now increasing numbers of physicians are employees of for-profit corporations.  Physicians and other health professionals who sign on as full-time employees of large corporate entities have to realize that they are now beholden to managers and executives who may be hostile to their professional values, and who are subject to perverse incentives that support such hostility, including the potential for huge executive compensation.  It is not clear why physicians seem to be willing to sign contracts that underline their new subservience to their corporate overlords, and likely trap them within confidentiality clauses that make blowing the whistle likely to lead to extreme unpleasantness.

It could also be that physicians are troubled by slightly less direct corporate influences.  We have blogged about 
- suppression and manipulation of clinical research by corporations sponsoring such research to assess their own products and services
- deceptive corporate practices like stealth marketing of stealth lobbying
-  financial arrangements among physicians (and other health professionals) and health care corporations (e.g., drug, biotechnology and device corporations) which often seem to deliberately produce conflicts of interest meant to help market products and services, particularly the use of paid "key opinion leaders" as marketers
- institutional conflicts of interest that involve academic institutions, disease advocacy organizations, and other non-profit groups in corporate marketing and public relations

 Furthermore, stories about and criticisms of these issues remain markedly muted in the media, and even more muted in medical and health care scholarship and scholarly journals.  We have attributed this anechoic effect to individual and institutional conflicts of interest, fear of offending conflicted friends, relatives, colleagues and supervisors, and fear of offending the rich and powerful.

 Despite the anechoic effect, the article by Tilburt et al suggests that physicians want to reduce corporate influence in medicine.  Yet this evidence of physicians' discomfort with corporate influences itself has been greatly muted by the anechoic effect.

While the survey results are reminiscent of opinions I have heard from many physicians, it is striking that there is no perceptible organized movement by physicians against excess corporate influence.  At best, public expression of concerns about excess corporate influence has been muted and fragmented, often relegated to blogs and sometimes derided as coming from malcontents, dissidents, disgruntled employees, and other assorted trouble-makers.  But again it looks like the majority of physicians may (often silently) agree with these "whiners and complainers." 


Physicians need to realize that they mostly agree that to fulfill their oaths to put patients first, they have to reduce the influence of rich and powerful organizations, like health care corporations, with other agendas.  Maybe once they realize this, they will be able to start doing something to reduce such influences.  Maybe once they start, they will be able to rethink the notion that direct health care should ever be provided, or that medicine ought to be practiced by for-profit corporations. I submit that we will not be able to have good quality, accessible health care at an affordable price until we restore physicians as independent, ethical health care professionals, and until we restore small, independent, community responsible, non-profit hospitals as the locus for inpatient care.


Roy M. Poses MD on Health Care Renewal


References

1.  Tilburt JC, Wynia MK, Sheeler RD et al.  Views of physicians about controlling health care costs.  JAMA 2013: 310: 380-388.  Link here.

2.  Emanuel EJ, Steinmetz A. Will physicians lead on controlling health care costs? JAMA 2013; 310: 374-375. Link here.

Candid Nurse EHR Opinions at Facebook Page "Friend a Nurse" Are Not So Friendly

At my Jan. 2010 post "An Honest Physician Survey on EHR's" (http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html) I wrote:

I often believe surveys of physicians about EHR's do not present the results candidly, but rather are selective in what is reported - and what is omitted - and generally sugar-coated.

I then presented a candid physician survey on EHR's that was not very complimentary of the technology's value to real-world practicing physicians.

The following candid, informal nurse's survey about EHR's came to my attention the other day via Google.  The thread is on Facebook in the "Friend a Nurse" group pages and can be read at https://www.facebook.com/friendanurse/posts/654085127954821.

Apparently the thread got underway after someone posted the question "What do you think of electronic medical record systems? How was it implemented in your facility? Has it helped or hurt patient care? If so, how?" and a link to the June 25, 2013 Bloomberg News article "Digital Health Records’ Risks Emerge as Deaths Blamed on Systems" (http://www.bloomberg.com/news/2013-06-25/digital-health-records-risks-emerge-as-deaths-blamed-on-systems.html) that mentioned my mother's experience.

The EHR question posed on the "Friend a Nurse" Facebook page at https://www.facebook.com/friendanurse/posts/654085127954821.  Click to enlarge, or click Facebook link, which is public as of this writing.

I note that I had no knowledge of this, nor do I know the responders.  I did add a link to my Drexel website on health IT difficulties at the end of the thread, however, after I discovered it.

Here are the comments from both female and male nurses who belong to this Facebook group.  I redacted the names, however they can be seen at the Facebook page itself at the link above.

------------------------

Big problems when you have unexpected "downtimes".
July 15 at 1:10pm · 4

It is an absolute train wreck, I havent seen one record of mine that is not riddled with mistakes. Especially the allergies, they show me taking meds Im allergic too and not taking meds Im actually on.. A true mess!!And now the records are all intertwined. I dont like it at all!!
July 15 at 1:10pm

It is a nightmare!
July 15 at 1:18pm

I retired just in time so I don,t have to deal with this fiasco
July 15 at 1:19pm via mobile

IT SUCKS
July 15 at 1:19pm

I don't like them; my doctors don't like them; how it will affect patient care is still a 'jury out' matter, but we can guess it will NOT help.
July 15 at 1:30pm

our Rural Community Healthcare system is just now switching over to this..along with our hospital switching over to a totally new computer system..the 2 systems do not talk to each other..In my personal experience I find that the "computer" world takes us away from Direct Patient Care.(to busy playing "ring around the Rosie" on the computer..
July 15 at 1:40pm

I like them, but it is frustrating having "downtime."
July 15 at 1:41pm

I hear patients stating things like "my doctors don't know who I am because they don't look at me they are glued to the computer". It saddens me patients feel less valued. I've worked in places where they've had paper charts and places computerized. Seems the computers are redundant and I personally prefer paper charts. Chart one assessment not one assessment 4 different places.
July 15 at 1:44pm via mobile

It looks to me like physicians are cutting and pasting old histories and physicals, complete with the errors. Doctors in a local ER charted complete physicals on me when they did not get closer that 5 feet away. The records are difficult to read, difficult to find information, and not number in chronological order.
July 15 at 1:47pm

I dislike it . Besides the down time find it very impersonal . I don't feel as if I am giving my full attention to my pt, nor do I feel my PCP is hearing what I ' m saying . They are to busy putting in info on the computer . As for the down time you then have to work late to put in the info gathered while the system is down.
July 15 at 1:47pm via mobile

Electronic charting takes the skilled nurse away from the patient and puts them in front of a computer. Its NOT best for the patient or staff - the people who build the programs have not been at the bedside for eons....so the programs are time consuming, redundant, and inefficient.
July 15 at 1:51pm

I like EMR very much. The system we use is Allscrips, it is not perfect, but the benefits outweigh the problems. For example, I find most issues are human errors, such as poor spelling, incorrect entry in the proper records, entering incorrect doses. I love the fact that I can actually read and do not spend time deciphering not only the doctors writings, but my coworkers. I like having all the records in one place. There are issues for sure, but some of the issues is from companies who chooses to,purchase low quality EMR packages with poor support. The systems also need to be more standardized and "speak" to each other better. And folks at the end of the day it is your license at risk, do the things you were trained to do in nursing school, the 5 Rs remember those?
July 15 at 1:53pm via mobile

we are starting on it, let you know
July 15 at 1:53pm

In general I dislike it. If it 'goes 'down', you end up being unable to obtain vital information. With the federal system we did have both the computer records and the paper records. This was fine with inpatient informaton. I dislike it when my computer crashes and I can't get anyone to come look at it or fix it. They had a message line which we never had a call back from. I'd have a whole dept be down and non one to repair it. It's very frustrating on a triage line. This made scheduling appts impossible. Lack of vital information could be lethal to critical care patients...Far less pro's than con's. It's just a bad decision all together..
July 15 at 2:01pm

if THE GOVERNMENT CAN GET INTO YOUR RECOREDS SO CAN ANYONE they can hack anywhere now a days and it is scary///
July 15 at 2:05pm

anyone over 25 most likely hates it
July 15 at 2:09pm

I quit 2011...did CPOE no issue but more more is coming seems like q mo. or so keeps adding dig. stuff...hosp. worked with kept changing sys...used to ask myself why fix when not broken also once you got use to it thats when they change...they shld hire more nurses aux. ppl...do not know what to do with their money. Stressout...no more nursing for me . New grads savvy but this boomer did it for 38 yr. Enough is enough!!
July 15 at 2:14pm via mobile

Takes time away from pt care too much:-)
July 15 at 2:34pm

I work in a hospital and I hate it! I feel like I spend more time looking at the computer than at the patient. We have to document the same thing in multiple areas...big waste of time! Also our ER and OR's use a different program and we are not able to access this information when a patient is admitted to the floor. We also use Physician OE and the system we have it is hard to get back to look at an already viewed order. I feel this is dangerous and orders are missed all the time. It is just a ticking time bomb before someone is going to get hurt!
July 15 at 2:35pm

The med was there then disappeared.....software is only as good as the person using it. A PERSON DELETED THE MED! Pharmacies, nurses, and MDs use the computer did it as an excuse. Never understood how I corrected MARs every month and they were worse the next month...the computer did not do it alone. I dislike the MD playing on the computer and half listening to me.
July 15 at 2:38pm

Recently I have had md's not put a patient back on home meds because he/she could put them in correctly. I had to call the doctor on call at night to get these medications in place. The pt was also missing vital medications they needed for their diagnosis. I feel like in some cases emr is not safe. There however some cases where emr is helpful.
July 15 at 2:43pm

it will get better with time...
July 15 at 2:45pm

I worked at a VA until I retired, and I loved it. It is so much easier. Lets face it, anyone that wants your information is going to get it anyway.
July 15 at 2:57pm

I have used EMR in hospitals, home health and hospice for the past 20 yrs. When used within the same corporation w many offices it is very efficient. In that state corrections dept it was very helpful w continuity of care. the medical record follows the inmate to what ever unit they may transfer to. HIPPA is even more important with the EMR systems.
July 15 at 3:14pm

We just changed our system to a new one. It took a large group of staff over 18 months to develop our documentation system. The nursing portion is great. The med ordering part is difficult to use. The docs are all complaining about the system. They want to continue writing their orders.
July 15 at 3:17pm via mobile

We have had epic for over 5 yrs it is a great system.just wish computers worked better always having to shut down and reboot. Has saved us a few times with preventing med errors.covenant healthcare did a great thing when they got this system
July 15 at 3:18pm via mobile

I think it is an injustice to the Patients We are more than a computer file
July 15 at 3:24pm

It helps with a history when a patient is unable to provide
July 15 at 3:29pm via mobile

Plus it may have contacts address patients previous baseline behavior I'm a psych nurse so we utilize this type of system
July 15 at 3:30pm via mobile

Takes time away from patients, goes down too often, difficult when hospitals change systems. There should be a universal system, so info can be shared.
July 15 at 3:40pm via mobile

EPIC is terrible when it comes to outpatient chemotherapy and research. It is cumbersome and takes so much time away from patients. EMR's are here to stay and I think it's a great thing, for the most part, but sheesh make it easy on the provider, will ya?
July 15 at 4:07pm

we fear medication errors because some doctors start up home meds that are no longer correct. getting used to it is the hardest. the younger nurses are much more efficient and comfortable with it.
July 15 at 4:16pm via mobile

I agree with Noelle, it took focus away from the patient because it was cumbersome and repetitious, and because of the environment we had to keep the people moving through recovery....so it was dreadful. I was happy to retire and leave it to others to deal with.
July 15 at 4:30pm

I've worked with electronic T-system, Promed blue, Meditech, etc and all have their advantages and disadvantages, but the major disadvantage is that we don't do patient care anymore...we do computer care...I could also go on and talk about the fact we also don't get to spend as much time with our patients because of patient ratios and patient loads and the computer charting we have to get back to...
July 15 at 4:32pm via mobile

you are right on target here.....I retired because of this, there is very little patient care, it is indeed computer care !
July 15 at 5:00pm · 1

Nursing Informatics Institute How has nursing been involved in the planning and implementation of these systems? Feel free to share your experiences, it is very interesting to hear about your practice.
July 15 at 5:15pm

I love the electronic records. I do not love all the different styles ect programs out there. So many glitches. Patient's need to be proactive and as involved in their healthcare and that of their loved ones as possible. That means bringing ALL of your med bottles with you to each and every doc visit you go to. I don't care how many times or how many diff docs you see in a week, ALWAYS take ALL of your meds in the ORIGINAL bottles. Where I work there is 100+ doc's in this group, each doc office has access to same record I see when the patient comes to us. Each doc office can ad or make changes to the chart accordingly, so if you don't bring your meds with you to each visit and doc A changed a med and made the notation in the chart we see it but can't verify it. ALWAYS keep an updated list of meds in your wallet/purse for those emergencies when you don't have your meds. Include on this list, your surgical history, your medical history(Diabetes, hypertension ect ect ect), who your PCP is and a #, allergies, blood type, your wishes as far as DNR ...... It will save your loved ones precious time and allow them to focus on you, and not that new pill doc so & so started you on for her diabetes, I think. Anyway, with so many spoons in our medical records here, I catch mistakes all the time where a med has been deleted/added ... By another office. Usually because the patient did not bring the meds, or the patient is a poor historian of their own medical history and the family has no clue. Be proactive people, don't trust us to do it all. Get the dam electronic records fixed so they make sense, and stops all this confusion ..... Why so many different types and formats are needed is beyond me.
July 15 at 6:01pm 

not the systems that cause the problems, staffers that program only what they think is important when making diagnosis.
July 15 at 6:37pm

Love it - but when they go down.....
July 15 at 6:39pm

Mostly like it. Rather type than write. Does take more time than paper note, but overall I like it. I agree when I see patients & when I or my family is the patient, MD hardly looks at you; too busy inputting data.
July 15 at 6:52pm via mobile

No Comment.
July 15 at 6:52pm 

it is a huge improvement! and a potential life saver - no more figuring out what that handwriting is saying.
July 15 at 7:13pm

I generally like EMRs but some programs are so damned redundant (charting the same IV start every time you admin an IV med?) and/or lacking in -- how do I put it? -- intuitiveness. Sometimes I really wonder if anyone actually working with patients was involved in the design or implementation of some of the programs we use.
July 15 at 7:31pm 

Has it's good points and bad points. But I spend more time on the computer, then at the bedside.
July 15 at 7:55pm

I think computer charting has went way overboard and takes the nurse away from the bedside. How does family view nurses that are at the desk on the computer all the time?
July 15 at 8:27pm

it is disconcerting to the patient and or family if the health care provider starts firing questions and then spends the entire visit looking through the chart instead of listening to the patient's effort to provide a history of symptoms. No eye contact diminishes the interaction significantly!
July 15 at 9:15pm

for some things they are O.K. but everything no. Maybe scanned for some things. Now I have not thought out a plan for which, maybe someone with more time than I have could do a better job.
July 15 at 11:36pm

Haven't seen it work too well.
July 16 at 1:04am

It takes a lot of patience to get it implemented into a facility. The inservices that we
have had are few and basically it is a learn as you go. When everyone is finally sure of how to do it, it will be OK but is taking a long time for all of it to be taught to us
July 16 at 7:31am

mountains of paper, I mean mountains...
July 16 at 10:22am

as nurses, we are buried in paperwork... so are the docs... looking for a way out, we all THINK the digital answer with EMR is THE way... BUT nobody has proved it is superior, or really saves time or workload... and now the GOVERNMENT is pushing us into a costly and complex system
July 16 at 11:14am

------------------------

I think the comments (largely negative with several "positive but with significant concerns") more accurately reflect EHR reality "in the trenches" than the marketing propaganda emanating from government, the health IT manufacturers, the academic pundits, and other "see no evil, hear no evil, speak no evil" triple-simian hyper-enthusiasts.

On EHRs:  see no evil, hear no evil, speak no evil

Of course, the hyper-enthusiasts will call these opinions "anecdotal", but as one investigative reporter who does work in the EHR sector opined when sent the Facebook page:  

"That's a lot of anecdotes."

-- SS

An Honest Physician Survey on EHR's

I often believe surveys of physicians about EHR's do not present the results candidly, but rather are selective in what is reported - and what is omitted - and generally sugar-coated. Examples of very candid reports are rare, probably due to pushback, such as this recent report on ED EHR's in New South Wales from Australia.

Often the pushback takes the form of the report "lacking peer review", which in a non-free market, vendor-dominated situation (as in pharma, with money flowing everywhere but up) is as likely to produce censorship or, at best, groupthink, as objective science.

Here is one that is candid, by the American Association of Physicians and Surgeons.

The Association of American Physicians and Surgeons , founded in 1943, regularly testifies before the U.S. Department of Health and Human Services regarding development and implementation of health information technology. It consists largely of physicians in private practice. I've been a member of the organization, but was not at the time this survey was performed and written up:

PHYSICIAN ATTITUDES & ADOPTION OF HEALTH INFORMATION TECHNOLOGY (PDF)

Results Compiled on 6/9/2008

Specialties Responding:

Family Practice 73
Psychology 38
Internal Medicine 33
OBG 27
Orthopedic Surgery 27
Ophthalmology 26
General Surgery 22
Dermatology 21
ENT/OTO 15
AN 14
Neurology 13
Pain Management 13
Urology 12
Pulmonary
Diseases 11
Neurosurgery 8
Vascular Surgery 6
Cardiology 5
Radiology 5
Gastro 5
Emergency Med 4

I am simply reproducing some of the comments received below without additional comment:

A patient's medical history is nobody's business but the doctor's and the patient's.

All EHRs examined are cumbersome and ineffiecient

As a 'computer programmer,' can see pushing buttons to make statements about a patient's health, really makes patient care more distant, takes the personal, hand-touched art out of practicing medicine, AND lends itself to inaccuracies and errors

As a primary care physician, I rarely see patients for one problem, yet most EHRs Ive tested are based on the 'problem/visit' models.Expanding the visit to include the 'oh, by the way, doc's' is cumbersome and even more time consuming.

Better--paper record (for patient, also, to keep)

Big Brother is watching you--1984

Can't view my study printouts and look for change--pages 'turn' too slow

Comment: I do write notes on my computer but it is not part of any 'system.' I do not send bills via computer.

Comment: as anesthesiologists, we use the hospital's EMR, but we haven't implemented our own. Possibility that it won't lead to improvements in quality of care

Comment: However, I work with a physician's group to promote EHRs and run into many obstacles

Comment: we have spent upwards of $200,000 on Nextgen software plus hardware for our clinic and have never been able to make it function over the past 5 years

Compatibility

Concern about presumed access to record by multiple non-insurance third parties.

continued cost of support, maintenance, and updates of hardware and software

cost benefit ratio too high

Cost of upgrades

degradation of personal dr/pt relationship. Instead of a conversation between two people there is the intrusion of a mechanical 'other.'

Distraction from personal patient care

diverts attention from patient to data processing

Doesn't work. Studies show no better. Push for EHR due to 'Big Brother's' appetite for info and control.

Don't need it or want it. Concern about accuracy. Many of the automated consult letters I receive contain glaring errors and omissions.

EHR generates false pre-programmed info that does not truly reflect the time actually spent with the patient allowing the MD to 'upcode' for the visit and bill higher. It is more honest for me t spend 20' with my patient and write wo words of actually pertinent info.

Ehr in use for nurses only at my second site and it slows down the care they give.

EHR is most impersonal. It does not give a fell for what is going on with patient.

EHR notes are poor, very poor. Full of useless verbiage and usually no place for physicians to add specific notes (or they are lost in the mass of irrelevant detail automatically supplied by the program. Also encourages physicians, who are often pressed for time, to make any specific notes.)

EMR are very time consuming, result in production of lengthy repetitive notes of questionable clinical value and reliability.

Comment: companies go out of business and new systems need to be installed.

Comment: Federal and state govt. will continually add requirements

EMR printouts contain extensive boiler plate data. The real data is hard to glean from the chaff.

Fills the chart with negative (non-used) information

Getting the computer 'right' will become more important than taking care of the patient.

Have started process

Have used EHR and find written records more reliable and practical

I am a fulltime ER doctor. I have no say but if they go electronic, I go.

I am blind

I am concerned with control that's being exercised here. There's no room for creativity, judgement and financial shortfalls. If the government or insurance companies would take the overhead including this financial then it might be palatable

I am not a good 'typer'--on a keyboard--I do not type at all. Don't want to type, never will. I am not trained as a secretary or clerk.

I do not want to have to turn on a computer everytime I speak to a patient or need a chart with consulting with another physician or a pharmacist.

I feel like I would be a secretary to enter data on my patients so that government can easily slide into socialized medicine.

I hate typing and anything that distracts me from writing and examining

I have not found a system that will speed up my patient encounter. All make it slower--with keyboard--not patient--time.

I see no benefits; would certainly disrupt my thinking process.

If mandated--no standard for format. Took 15 years to finally get standard for electronic billing.

If purchased would be faced with frequent expensive changes to format. They still can't get the new NPI number to work! Everyone I know who spent $50,000 to buy a system either junked it or are planning to!

In 2000, I lost my billing staff. Led to a computer-based billing system due to that. The transition was horrible! I could not use the system myself and training for staff was expensive; the IT guy was expensive; billing personnel who had experience with my system were few. In the end, 4 years later, I had an AR $136,000 and as aconsequence, I closed that practice

Inappropriate EMR causes defocus from reason for visit, etc. Problem with sketches.

Still would need 2 charts--one paper, photos, etc. and 1 EMR

Inefficient. They do not provide the clinical data that I need.

It is impossible to skim through an electronic record to find data. It is impossible to sketch the affected anatomy in electronic records. If the computer breaks down or the technology becomes obsolete, the patient record disappears. It takes too long to enter data into a computer.

You still need a paper chart to share reports and other patient paper records.

It will be of no value in my single practitioner spine surgery practice lack of any standard format/compatibility of various systems

Lack of personal patient interplay

Less time with patient, more time with computer. There are better ways to give ER docs access to patient's med records. Survey ER docs to learn what info they would need when pt. is unconscious. Put that into pt. ID card using 2D Barcodes or magnetic strips. Card readers in ERs can then access that info. If AAPS helped develop and sponsor this for its members, it could be a source of $$ for AAPS

loss of dr-patient relationship

Loss of patient control over privacy of records

Loss of quality of patient's personal records. Physical deterioration of data over many years

Inadequate accuracy of voice recognition technology Lack of evidence that EHRs
are any better or equal to paper records except in narrow applications

I purchased an EHR system and was unimpressed. Main reason: prefer personal notes. I believe dictated notes are more specific and detailed and are customized for each patient visit

May not be able to get to computer records in case of computer crash or power failure (eg. Katrina).

most software have major problems in functionality and changes how physicians practice in a potentially negative way

Must have voice recognition for input at 100% accuracy and reliability.

my patients are given copies of all reports (lab, x-ray, consults) as they are collected and told to keep in their medical file

No adequate voice recognition systems

No clinical evidence that this improves outcome. No clinical evidence that there is a return of investment.

No evidence that EHR will improve care or reduce costs to the patient/doctor/healthcare system.

No improvement in quality of care provided.

Once they force us into the more expensive, time-consuming system that does not work, they
own us! It is too easy for the courts, government, hackers and insurance companies to take 'all,' once it is in the system!

One of worst business decision we made.

open source software is available (but VA Vista split into Open Vista and World Vista groups and is written in a language that is not known to many programmers) but I haven't taken the time to find something that could work--I don't know if any of them can keep up with the government requirement

oppose all government interference

Paper charts are much more accurate and efficient for me.

Patient safety

perpetuation of errors

Preoccupation with the computer takes time from patient. Increased errors from EMR especially CPOE. We already have well established safety checks and reviews in our system for tracking tests and medicines. No system especially CPOE have been tested for safety and efficacy nor approved by any regulatory agency and thus the alteration of care from these (?) is nothing but an experiment and patients have not signed consent. Preoccupation with the computer takes time from patient. Increased errors from EMR. We already have well-established safety checks in our system for tracking tests and medicines. No systems have been tested for safety and efficicacy nor approved by any regulatory agency

Reduced time with patients. My patients complain about other doctors playing with EHR computer instead of looking at them during visit.

reliance on psychological pen and paper tests

Slower system than handwritten notes

slows review of chart at each office visit

some parties are paying $10,000 per month for technical support

Sorry, I cannot fill this out--I have visual problems

Still building the software

Studies are not showing conclusive evidence that EMRs improve patient care or safety, but do increase practice costs.

systems are difficult to implement; I've been trying for 2 years

The EHR in the hospital slows me down. A paper record is more efficient for me.

The systems seem to impede quality clinical care and passing along of relevant clinical information

There is not one advantage to me, at all!

There is one product I would use, PRAXIS. [www.informed.com] I would need $30,000 infrastructure and $30,000 adoption overhead grant in order to do so

They don't improve patient care--just adds to overload

time taken up up for data; focus on computer rather than on patient in the exam room

Too rigid. I like to draw pictures of what I see on ophthalmological exam.

Typed, dictated note can be read much more quickly. I use a print about 1/2 the size of your print on this page and there are perhaps 4 or 5 pages of regular print per page which I read without glasses. Computer and power problems do not hide my records.

Unfunded mandate with huge cost in a severely declining reimbursement arena.

without a personalized note, it is worthless.

Read the entire report as linked above. No additional comments are needed.

-- SS

"Academic Doctors Increasingly Despair at Push for Revenue Over Research"

An important article on the state of academic medical faculty appeared in Academic Medicine [Schindler BA et al. The impact of changing health care environment on the health and well-being of faculty at four medical schools. Acad Med 2006; 81: 27-34.] The article was summarized in the Chronicle of Higher Education with the provocative title, "Academic Doctors Increasingly Despair at Push for Revenue Over Research, Study Shows."

The authors surveyed faculty at four medical schools in the east, southwest, and western US, three state supported, one private, in 2000 and 2001 up to September 11. Some of their most striking findings were:

• Academic physicians spent an average of 40.7% of their time in direct patient care (up from 23% in a 1984 survey).
• Academic physicians spent less time supervising residents and medical students (15.2%) than they did in 1984 (21%), and overall spent only a little over a quarter of their time overall in teaching and related activities.
• Academic physicians spent less time on research (14.7%) than they did in 1984 (29%).
• One fifth (20.5%) of faculty were clinically depressed as indicated by scores of 16 or greater on the CES-D scale.
• About 11% of faculty had moderate to severe anxiety.
• One quarter (25%) of faculty had salaries completely dependent on their "productivity." More than one-tenth (12.6%) of faculty were contemplating leaving their institution within the next few years. Only 18.5% of faculty thought their institutions were in good financial shape.

Some notable comments in the discussion section were:

The future of medicine resides in the medical students of today and tomorrow, who in turn depend on the quality of faculty and teaching in our nation's medical schools. This study raises the concern that current medical students are being taught by faculty who are increasingly stressed and dispirited.
For many faculty, the lure of academia seems to have been the relatively stable mix of patient care, research, and teaching. Yet our study supports LUdmer's assertions that in recent years patient care responsibilities have burgeoned, crowding out time for teaching and research.

The title of the Chronicle article seems a bit more to the point, though. Something is very wrong when one-fifth of academic physicians are working while clinically depressed.

The authors of the study did not talk much about the source of the stresses under which the faculty labored. Persual of Health Care Renewal would suggest that many of them realized they were working in a health care environment that had decreasing interest in training the doctors of the future, and increasingly threatened their core professional values. Some may have realized that the financial pressures to which they were exposed were partly a result of health care organizations that sent most of the money elsewhere, some of it wasted in foolish pursuits and cumbersome bureaucracy, some handed as lavish salary and perks to undeserving managers, perhaps a bit of it literally stolen. That truly could make honest academic physicians depressed.

Public Perceptions of Causes of High Health Care Costs

USA Today has run a series of articles on health care costs. Particularly relevant was one that summarized results of a poll done jointly by USA Today, the Henry J. Kaiser Family Foundation, and the Harvard School of Public Health of over 1500 adults in the spring of 2005.
The poll asked about the importance of a number of factors as causes of high health care costs. The summary below lists the factors, the percentage saying they were very important, and the percentage saying they were the most important cause of high health care costs (see these results on the web here).

High Profits Made by Drug Companies and Insurance Companies 71%, 37%
Number of Malpractice Lawsuits 58%, 19%
Amount of Greed and Waste in the Health Care System 59%, 15%
Aging of the Population 50%, 8%
Use of Expensive, High-Tech Medical Equipment and Expensive Drugs 46%, 8%
Insured Patients Have Little Incentive to Look for Low-Priced Services 34%, 5%
Doctors Making Too Much Money 31%, 5%

What's fascinating is that many in the public seem to perceive that the sorts of issues we talk about on Health Care Renewal, e.g., "high profits made by drug companies and insurance companies," "malpractice lawsuits," "expensive, high-tech medical equipment and expensive drugs," and notably "greed and waste," are important drivers of health care costs. Yet these are not the sort of issues that health care researchers and policy makers tend to talk about.

National, For-Profit Managed Care Organizations Are the Least Trustworthy

I just learned about a recent article in Health Services Research on trustworthiness of managed care organizations that had some fascinating results. (The full citation is Schlesinger M, Quon N, Wynia M, Cummins D, Grey B. Profit-seeking, corporate control, and the trustworthiness of health care organizations: assessments of health plan performance by their affiliated physicians. Health Services Research 2005; 40: 605-646.)
The investigators used data from the American Medical Association's Socioeconomic Monitoring Survey from 1998. They focused on responses from 1274 physicians who had at least one managed care contract to questions asked about the health plan that enrolled the largest number of patients from the physician's practice. The distribution of responses to some of these questions were striking.
How often do the plan's advertisements create an inaccurate impression of its benefits?
Sometimes 30.7%
Often 18.9%
Always 7.2%How often are patients often confused about plan benefits?
Sometimes 36.1%
Often 36.0%
Always 11.9%
How often does the plan forces physicians to compromise their standard of care?
Sometimes 23.6%
Often 6.3%
Always 1.3%
Furthermore, in multivariate analysis, for-profit national plans were rated by the physicians as less trustworthy. For the variables listed above, the odds ratios (approximation of the relative risk) for less favorable responses were:
Ads create inaccurate impression of benefits - 1.69
Patients often confused about benefits - 1.71
Plan forces physicians to compromise standard of care - 1.67

In summary, physicians frequently think that managed care plans run advertising that create false impressions of the plans benefits, confuse patients about their benefits, and force physicians to compromise their standard of care. National, for-profit plans are more likely to behave in such untrustworthy fashions than local and not-for-profit plans. Some points in the authors' discussion, couched in the typically cautious language of scholarly journals, merit repeating:

The managed care industry changed dramatically between the mid 1980's and mid-1990's. The ownership of health plans by large, for-profit corporations expanded markedly
Our findings suggest that the managed care backlash that appeared in the mid-1990's may have been a result of this transformation of the industry....
It is essential to recognize that these segments of managed care are growing rapidly because public policies have encouraged that growth.
Many states have enacted a plethora of regulation applied to managed care practice. As yet, little is known about the efficacy of these interventions, although state resources for enforcement are quite limited. Under these circumstances, public policies that encourage a larger role for more trustworthy forms of managed care may prove a more feasible form of intervention....

However, at the moment, we are instead seeing larger and larger for-profit national managed care organizations being formed by mergers. The most recent example is the merger of UnitedHealthGroup and PacifiCare. The important article by Schlesinger and colleagues suggests such mergers do not bode well for doctors or patients.

An Australian Survey of Threats to Research Integrity

Another important article on threats to the integrity of clinical research has appeared in the Medical Journal of Australia. (Henry DA et al. Medical specialists and pharmaceutical industry-sponsored research: a survey of the Australian experience. Med J Aust 2005; 182: 557-560.)
The authors sent a survey to 5000 Australian specialists, excluding general practitioners, but also surgeons and anesthesologists, and obtained a 39% response rate. 388 specialists (41% of respondents) had done pharmaceutical industry sponsored research. Of these,

• 100 (25.7% of those engaging in research) reported that the first draft of a research report was written by pharmaceutical company or contract research organization personnel
• 55 (14.2%) reported a delay in presentation or publication of key study findings
• 41 (10.6%) reported failure to publish key findings
• 22 (5.7%) reported editing of the report to make the drug appear better than was justified by the study results
• 18 (4.6%) reported concealment of relevant findings.

This study suggests that manipulation and suppression of research results in favor of commercial research sponsors' products is an international pheonomenon, and one that involves not only academic researchers but those in private practice.
An accompanying editorial (Gotzsche PC. Research integrity and pharmaceutical industry sponsorship. Med J Aust 2005; 182: 549-550) suggested that "testing drugs in patients" should be "a public enterprise." It asked, "who would buy a washing machine that is five or 10 times more expensive than other washing machines just because its manufacturer has compared it with other machines and claims that it is the best?"
Thanks to Sue Pelletier's Capsules blog for the tip.

Major ACPE Survey on Unethical Business Practices in US Health Care

The results of a very important survey have just been published by the American College of
Physician Executives (ACPE). A summary of survey data is here. The full article, entitled "Unethical Business Practices in US Health Care Alarm Physician Leaders," is here. An American Medical News article summarizing some aspects of the results is here.
Basically the ACPE designed the survey to determine "how have physicians - along with other health care providers - responded to the universal seep of commercial imperatives into the modern practice of medicine." It surveyed about 1500 ACPE members (a 21% response rate). Of those responding, 10.1% were CEOs or the like, 28.8% were at the vice-president, CMO, COO, CIO level or similar, 17.9% were medical directors, 24.5% had academic leadership positions, and 18.6% were practicing physicians, consultants, or house-staff.
The results that were most striking and relevant to the issue of external threats to physicians' professionalism were as follows.

• A large majority of respondents were quite concerned about "unethical business practices affecting US health care today." (54.6% were very concerned, 35.6% were moderately concerned).
• Significant proportions of responders were concerned about unethical business practices within their own organization. (33.1% thought that there were one or more physicians in the organization "involved in unethical business practices;" 11% thought there was a board member "involved in unethical business practices;" 14.2% thought there was a non-physician administrator "involved in unethical business practices.")
• The majority, 53.8%, could identify another health care organization in their community "involved in unethical business practices."
• Although most, 70.1%, said that their organization had a written code of ethical behavior, only 59.7% of them said the code was actually enforced.
• A large majority, 80.8% agreed that "professional organizations need to promote tougher ethical standards."
• Most respondents evinced concern about a variety of unethical practices by physicians. In addition, most were concerned about board members or non-physician executives with conflicts of interest (33% very concerned, 33% moderately concerned about the former, 34% and 32%, the latter.) Most were concerned about board members or non-physician executives accepting gifts from vendors (27% and 29% re the former, 34% and 32% re the latter.)
• Finally, when asked who was responsible "for sowing the minefield through which today's physicians have to try to pick a righteous path," they named a variety of types of large health care organizations, health care plans and health insurers, pharmaceutical and device manufacturers, hospitals and health system, and malpractice attorneys.
• Finally, respondents provided some pithy comments."Our health care system is designed to encourage unethical behavior by its misplaced financial priorities." "Current medical practice on a corporate level is schizophrenic." "Ultimately, the bottom line corrupts absolutely!" "'Business ethics'... an oxymoron?"

In summary, although its small response rate is a limitation, this survey begins to quantitate the scope of some of the issues we have discussed on Health Care Renewal. It suggests that our concerns about threats to physicians' professionalism due to concentration and abuse of power are not exaggerated. If physician executives are this worried, it suggests that doctors in the trenches may be even more so.
Now the question is how can we get the folks with these concerns together, and figure out what to do about them?