I recently attended some training on the clinical uses of Second Life. Second Life is a live, interactive, server-based software that enables users from all over the world to communicate and interact. It appears as a cartoon-like environment with 3-D features.
The University of California, Davis Health Informatics Program offered the training as a part of their Health Informatics course on The Internet and the Future of Patient Care. Instructors Bernadette Swanson and Peter Yellowlees provided several one hour instructional lessons and tours of the Second Life environment and how it could be utilized for patient care.
What struck me as most interesting was the sheer number of people that were live on the Second Life application. On the average, there were about 75,000 at any given time.
The instructors demonstrated how training of medical providers could be carried out online for tasks such as mass casualty incidents. In fact, the digital world was complete with a hangar, virtual patients and medical supplies. I found the experience exciting. Clearly, this online training will be vital for the training of groups of providers that cannot necessarily travel for training. One example would include rural EMT's that need biochemical disaster training but cannot leave their posts because of staffing issues.
Dr. Peter Yellowlees demonstrated other types of training in his Virtual Hallucinations project. In this part of Second Life, the public can tour the Virtual Hallucinations building and experience near to life visual and auditory hallucinations.
More importantly, I can see the roles of doctors and patients changing. Currently, physicians see patients in an office setting in what is called a face-to-face meeting. With the advanced technology of Second Life, doctors and patients could meet in the virtual world, interact, and complete relatively simple consultations.
Before the introduction of email, patients could speak to their doctor on the phone. Email can sometimes be informal and at times proves to make understanding context difficult. Now, with the Second Life application, patients can virtually interact with their physician without the need for traveling. Imaging going to the doctor without even having to get out of bed!
But will this create referral problems? Competition for patients is not currently a problem because of geographic locations of providers and patients. However, with the virtual environment patients could teleport to be evaluated by hundreds of providers. Will this change the doctor-patient relationship to that of eBay?
Let's hope that doctors will still be doctors and patients will still be patients. However, increasing access to providers is key. I look forward to working more with Second Life for the Future of Patient Care.
Jonathan S. Ware, MD
Saturday, October 3, 2009
Monday, August 24, 2009
Malpractice Attorneys Eager for EHR
In her blog on EHRWatch.com, Patty Enrado discusses a different argument for adoption--malpractice law suits.
The title of her blog is "Are tort lawyers anxiously waiting to use EHR's in malpractice suits?" In her blog, she makes reference to an article published by Dr. Samuel Bierstock in Modern Medicine last week. Dr. Bierstock discusses his concern for President Obama's focus on adoption of EHR and not tort reform.
Many physicians fear adoption of EHR will put them at increased risk. In fact, if you really sit down and talk with physicians who have not adopted an electronic record keeping system, most will express concerns of increased liability.
It is rare to find a profession that is in constant risk of law suits that can be devastating not only to their career but to their families, homes, and assets. Dr Bierstock goes on to explain, "how many of you would want to use such a system in your work knowing that your every thought and action could be audited and evaluated by others who make their living suing you?"
EHR's can track how long a doctor looked at a document, if he or she scrolled down to read the entire thing, how long it took to respond to an alert or notification of an abnormal result, how long it took to answer e-mail, and the accuracy of every assessment and action. It can track whether their decisions meet the most recent guidelines or research results in a world where thousands of new papers and research results are published every week.
I think that Dr. Bierstock stated it quite well when he said, "Personally, I might like to know that I can finish dinner or brush my teeth before responding to a real-time alert that someone's blood sugar was a little high without someone suing me because I took too long to act." As a practicing physician and an active member of the American Health Lawyers Association, I completely understand his concerns. As healthcare providers our training teaches us how to approach problems and how to solve them. Our training also teaches us to anticipate adverse events and to weigh the risks and benefits of a treatment or action before proceding. Of course, physicians are going to be hesitant to change something that may actually be hazardous to their career health and stability. Maybe EHR's should come with a label on the side just as cigarettes do.
Putting reactivity aside, how do we sift through this air of mistrust? The Institute of Medicine's publication 'To Err is Human: Building a Safer Health System' in 1999 illuminated the unfortunate reality of medical errors in the healthcare industry. Realizing that many of these errors could be prevented, the Joint Commission (formerly JCAHO) set out to help change this trend.
Anyone in healthcare knows that nervous feeling when they hear, "The Joint Commission is here today." The nervousness doesn't come from guilt; it comes from the fear of getting fined for the small stuff. Getting fined $10,000 for having an open water glass at the nurses station seems a bit ridiculous--but it is a rule.
On the other hand, organizations like The Joint Commision have made 'root cause analysis' part of our vocabulary. In short, root cause analysis is defined as a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. But the purpose of root cause analysis is to actually prevent bad outcomes in the future. Many times medical errors do not reflect malice or negligence.
Learning from mistakes is key. Institutions utilize the root cause analysis method to clearly identify factors that can be addressed that can possibly prevent a bad outcome from occuring. Most cases of medical error can be mitigated if it is shown that the institution is aware of the basic or causal factors AND has instituted a risk-reduction strategy to address such factors.
If we are implementing EHR's, then it seems logical that we will discover inefficiencies and areas that require improvement. One of the founding principals for root cause analysis is that blame be shifted away from individuals and more towards organizational processes or risk-reduction strategies. Will the malpractice lawyers allow us to do root cause analysis as we roll out EHR's or are they lying in wait to pounce on the first ones to stick their necks out? I fear that the latter is true.
There are already many cases that have been tried using EHR's as the witness. I discussed this very topic with a colleague from a hospital consortium near Los Angeles recently. He explained that he acted as a defense expert in a Federal Court where he found the care of the patient to be excellent but the judge misinterpreted the EMR and seemed computer iliterate. Further, the software company responsible for the EMR actually "hung [the defense] out to dry."
I am excited about the future of electronic health records. However, I even more excited about what types of tort reform are coming to help protect the "medical public."
Jonathan S. Ware, MD
The title of her blog is "Are tort lawyers anxiously waiting to use EHR's in malpractice suits?" In her blog, she makes reference to an article published by Dr. Samuel Bierstock in Modern Medicine last week. Dr. Bierstock discusses his concern for President Obama's focus on adoption of EHR and not tort reform.
Many physicians fear adoption of EHR will put them at increased risk. In fact, if you really sit down and talk with physicians who have not adopted an electronic record keeping system, most will express concerns of increased liability.
It is rare to find a profession that is in constant risk of law suits that can be devastating not only to their career but to their families, homes, and assets. Dr Bierstock goes on to explain, "how many of you would want to use such a system in your work knowing that your every thought and action could be audited and evaluated by others who make their living suing you?"
EHR's can track how long a doctor looked at a document, if he or she scrolled down to read the entire thing, how long it took to respond to an alert or notification of an abnormal result, how long it took to answer e-mail, and the accuracy of every assessment and action. It can track whether their decisions meet the most recent guidelines or research results in a world where thousands of new papers and research results are published every week.
I think that Dr. Bierstock stated it quite well when he said, "Personally, I might like to know that I can finish dinner or brush my teeth before responding to a real-time alert that someone's blood sugar was a little high without someone suing me because I took too long to act." As a practicing physician and an active member of the American Health Lawyers Association, I completely understand his concerns. As healthcare providers our training teaches us how to approach problems and how to solve them. Our training also teaches us to anticipate adverse events and to weigh the risks and benefits of a treatment or action before proceding. Of course, physicians are going to be hesitant to change something that may actually be hazardous to their career health and stability. Maybe EHR's should come with a label on the side just as cigarettes do.
Putting reactivity aside, how do we sift through this air of mistrust? The Institute of Medicine's publication 'To Err is Human: Building a Safer Health System' in 1999 illuminated the unfortunate reality of medical errors in the healthcare industry. Realizing that many of these errors could be prevented, the Joint Commission (formerly JCAHO) set out to help change this trend.
Anyone in healthcare knows that nervous feeling when they hear, "The Joint Commission is here today." The nervousness doesn't come from guilt; it comes from the fear of getting fined for the small stuff. Getting fined $10,000 for having an open water glass at the nurses station seems a bit ridiculous--but it is a rule.
On the other hand, organizations like The Joint Commision have made 'root cause analysis' part of our vocabulary. In short, root cause analysis is defined as a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. But the purpose of root cause analysis is to actually prevent bad outcomes in the future. Many times medical errors do not reflect malice or negligence.
Learning from mistakes is key. Institutions utilize the root cause analysis method to clearly identify factors that can be addressed that can possibly prevent a bad outcome from occuring. Most cases of medical error can be mitigated if it is shown that the institution is aware of the basic or causal factors AND has instituted a risk-reduction strategy to address such factors.
If we are implementing EHR's, then it seems logical that we will discover inefficiencies and areas that require improvement. One of the founding principals for root cause analysis is that blame be shifted away from individuals and more towards organizational processes or risk-reduction strategies. Will the malpractice lawyers allow us to do root cause analysis as we roll out EHR's or are they lying in wait to pounce on the first ones to stick their necks out? I fear that the latter is true.
There are already many cases that have been tried using EHR's as the witness. I discussed this very topic with a colleague from a hospital consortium near Los Angeles recently. He explained that he acted as a defense expert in a Federal Court where he found the care of the patient to be excellent but the judge misinterpreted the EMR and seemed computer iliterate. Further, the software company responsible for the EMR actually "hung [the defense] out to dry."
I am excited about the future of electronic health records. However, I even more excited about what types of tort reform are coming to help protect the "medical public."
Jonathan S. Ware, MD
Wednesday, August 19, 2009
Deinstallation of EMR's is the new trend?
In the August 2009 issue of Healthcare IT News, Molly Merrill discusses how deinstallation of EMR's has become a trend.
According to a report by Health Leaders-InterStudy, the Arizona area has seen a particularly high rate of deinstallation of EMR's recently. Arizona has been one of the leaders in EMR adoption since 2005 mainly because of pressure from political figures and a shortage of doctors in the state. In fact, Arizona's EMR adoption rate is high at around 20% compared to some lower areas around the country at 10%.
Because Arizona was part of the 'early adopter' movement, they now find themselves in the situation where they have paved the way but are feeling the repercussions. Many physicians have been dissatisfied with EMR companies' support and functionality. In addition, training was weak and usually given as a one time event. Now, with the congressional requirement for 'certification' and the CCHIT being the only agency left to certify EMR's, many early adopters are finding that they must deinstall what they have been using and then install another.
In one way, deinstallation can be viewed as a failure of a system. However, taking into consideration all of the above, I think this increased rate of deinstallation of EMR's really represents evolution--EMR 2.0!
Jonathan S. Ware, MD
According to a report by Health Leaders-InterStudy, the Arizona area has seen a particularly high rate of deinstallation of EMR's recently. Arizona has been one of the leaders in EMR adoption since 2005 mainly because of pressure from political figures and a shortage of doctors in the state. In fact, Arizona's EMR adoption rate is high at around 20% compared to some lower areas around the country at 10%.
Because Arizona was part of the 'early adopter' movement, they now find themselves in the situation where they have paved the way but are feeling the repercussions. Many physicians have been dissatisfied with EMR companies' support and functionality. In addition, training was weak and usually given as a one time event. Now, with the congressional requirement for 'certification' and the CCHIT being the only agency left to certify EMR's, many early adopters are finding that they must deinstall what they have been using and then install another.
In one way, deinstallation can be viewed as a failure of a system. However, taking into consideration all of the above, I think this increased rate of deinstallation of EMR's really represents evolution--EMR 2.0!
Jonathan S. Ware, MD
Thursday, August 13, 2009
911 calls: public or private?
We've all listened to the replaying of the Michael Jackson 911 tape from his death in June of this year along with many others over the years.
I was shocked to find out today that 911 calls aren't always private. In fact, there has been a big debate over the last 11 years just on this subject.
In her article earlier this year, "An end to 911 call replays?," CNN Correspondent Carol Costello explains the answer is not so clear. She explains that Ohio Senator, Thomas Patton is trying to pass legislature to prevent the airing of the audible 911 calls without the family's consent. Patton states that he believes that airing actual 911 calls constitutes a violation of medical privacy in some cases and should be protected as such. Patton goes on to say that he feels people will be less likely to call 911 in an emergency for fear that the call will be aired.
However, according to the Director of the Reporters Commission for Freedom of the Press, Rebecca Daugherty, "when you use 911, you are using a public service. It is not a private matter. You are asking for governmental help of some sort." Daugherty goes on to explain that the public needs to know that the 911 system is functioning properly.
Currently, about 24 states ban or restrict public access to 911 tapes. Recently, the Louisiana Appellate Court ruled that releasing 911 tapes violated the family medical privacy rights. Amongst the most restrictive are Rhode Island, Wyoming, and Minnesota.
Where do we draw the line when it comes to medical privacy? We have HIPAA and other privacy laws that are so strict and will not allow reporters to access celebrity medical records. But now we allow the entire world to hear an agonizing, dying elderly woman as she calls for help when her bed is on fire? Eric Zorn of the Chicago Tribune wrote an interesting blog about this balance. He ended his blog with, "To exploit them is a disgrace. To protect them, a duty."
Jonathan S. Ware, MD
I was shocked to find out today that 911 calls aren't always private. In fact, there has been a big debate over the last 11 years just on this subject.
In her article earlier this year, "An end to 911 call replays?," CNN Correspondent Carol Costello explains the answer is not so clear. She explains that Ohio Senator, Thomas Patton is trying to pass legislature to prevent the airing of the audible 911 calls without the family's consent. Patton states that he believes that airing actual 911 calls constitutes a violation of medical privacy in some cases and should be protected as such. Patton goes on to say that he feels people will be less likely to call 911 in an emergency for fear that the call will be aired.
However, according to the Director of the Reporters Commission for Freedom of the Press, Rebecca Daugherty, "when you use 911, you are using a public service. It is not a private matter. You are asking for governmental help of some sort." Daugherty goes on to explain that the public needs to know that the 911 system is functioning properly.
Currently, about 24 states ban or restrict public access to 911 tapes. Recently, the Louisiana Appellate Court ruled that releasing 911 tapes violated the family medical privacy rights. Amongst the most restrictive are Rhode Island, Wyoming, and Minnesota.
Where do we draw the line when it comes to medical privacy? We have HIPAA and other privacy laws that are so strict and will not allow reporters to access celebrity medical records. But now we allow the entire world to hear an agonizing, dying elderly woman as she calls for help when her bed is on fire? Eric Zorn of the Chicago Tribune wrote an interesting blog about this balance. He ended his blog with, "To exploit them is a disgrace. To protect them, a duty."
Jonathan S. Ware, MD
Sunday, August 9, 2009
Theory of Planned Behavior
Administrators at Kingston General Hospital in Ontario, Canada are using Icek Ajzen's Theory of Planned Behavior to help with the enterprise-wide and community-wide adoption of EHR.
Briefly, Ajzen's theory model combines attitudes toward behavior, subjective norms, and perceived behavioral control in combination with behavioral intention and actual behavioral control to predict behavior.
Ajzen's theory also suggests that it is not information or knowledge about how EHR will help outcomes that will motivate change; rather, intention and actual behavioral control. How do you get intention? You must first change belief systems.
Utilizing the Theory of Planned Behavior, administrators at KGH hope to tackle opposition from non-adopters. Enabling providers to switch to a paperless system, demonstrating that this change will improve outcomes, and creating a standard in the community should create the intention needed for change. KGH feels that if providers percieve that they have the ability to succeed and should transition to electronic health records by community norms then they will do so.
This theory has strength. In fact, many change management agencies use this theory to assist large corporations with implementation of global changes.
One area that the Theory of Planned Behavior does not clearly address is emotion such as threat or fear. Now that payors and government agencies are threatening reduced reimbursement for noncompliance, providers now also fear a negative financial impact if they do not comply.
The US could glean a lot from observing this theory. Currently, it seems that the focus is on threat and fear. Maybe the focus should be shifted to identifying Champion Physicians in the community that are paving the way for adoption. That should help change belief systems.
Jonathan S. Ware, MD
Briefly, Ajzen's theory model combines attitudes toward behavior, subjective norms, and perceived behavioral control in combination with behavioral intention and actual behavioral control to predict behavior.
Ajzen's theory also suggests that it is not information or knowledge about how EHR will help outcomes that will motivate change; rather, intention and actual behavioral control. How do you get intention? You must first change belief systems.
Utilizing the Theory of Planned Behavior, administrators at KGH hope to tackle opposition from non-adopters. Enabling providers to switch to a paperless system, demonstrating that this change will improve outcomes, and creating a standard in the community should create the intention needed for change. KGH feels that if providers percieve that they have the ability to succeed and should transition to electronic health records by community norms then they will do so.
This theory has strength. In fact, many change management agencies use this theory to assist large corporations with implementation of global changes.
One area that the Theory of Planned Behavior does not clearly address is emotion such as threat or fear. Now that payors and government agencies are threatening reduced reimbursement for noncompliance, providers now also fear a negative financial impact if they do not comply.
The US could glean a lot from observing this theory. Currently, it seems that the focus is on threat and fear. Maybe the focus should be shifted to identifying Champion Physicians in the community that are paving the way for adoption. That should help change belief systems.
Jonathan S. Ware, MD
Friday, August 7, 2009
Efficiency Paradox
Dr. Joe Bormel wrote an interesting blog recently titled, "Efficiency: Paradoxical Impacts of Technology - Southwest Airlines gone awry."
In his blog, Dr. Bormel describes his recent experience with what is called the Braess's Paradox. Very briefly, Braess's Paradox implies that adding extra capacity to a network can in some cases reduce overall performance.
I, too, have experienced this paradox. During a recent Rapid Response Team alert in the hospital, I needed to emergently treat a patient with an IV medication at the bedside. Previously, this medication was stocked in the code carts on each floor. However, after implementing the bar coding system at our facility, it was decided that for the overall good of the institution and patients (safety, cost, etc.), this medicine would be available only from the pharmacy via the an pneumatic tube delivery system.
During this emergency, I asked the nurse for the medicine. I was then told that we had to get it from the pharmacy. A few seconds later I was handed an order sheet to hand write the order so that it could be faxed to the pharmacy. It was then added to the patient's electronic medication record. After that, the pharmacist was able to dispense the medication and place it in the tubing system for delivery. After it arrived to the floor, the nurse needed to scan the bar code system in order to administer the medication to the patient. Finally, after a total of 5 minutes, the patient received the medication. The patient survived.
To the patient and me, the process felt like an hour. I understood the decision to keep the medication in the pharmacy as this medication is seldom used on each floor. Stocking each floor could create medical waste. In years past, I would have been able to grab the medicine and give it myself if needed. But that brings its own inherent risks (stocking, expiration dates, a physician administering a medicine normally administered by a nurse, etc.).
In summary, as we build systems to be more robust and safe, let's not forget that the extra steps in the process may very well slow us down and may possibly have worse outcomes. Being proactive by including clinicians and health informaticians in the research, development, and implementation of such products is key.
Jonathan S. Ware, MD
In his blog, Dr. Bormel describes his recent experience with what is called the Braess's Paradox. Very briefly, Braess's Paradox implies that adding extra capacity to a network can in some cases reduce overall performance.
I, too, have experienced this paradox. During a recent Rapid Response Team alert in the hospital, I needed to emergently treat a patient with an IV medication at the bedside. Previously, this medication was stocked in the code carts on each floor. However, after implementing the bar coding system at our facility, it was decided that for the overall good of the institution and patients (safety, cost, etc.), this medicine would be available only from the pharmacy via the an pneumatic tube delivery system.
During this emergency, I asked the nurse for the medicine. I was then told that we had to get it from the pharmacy. A few seconds later I was handed an order sheet to hand write the order so that it could be faxed to the pharmacy. It was then added to the patient's electronic medication record. After that, the pharmacist was able to dispense the medication and place it in the tubing system for delivery. After it arrived to the floor, the nurse needed to scan the bar code system in order to administer the medication to the patient. Finally, after a total of 5 minutes, the patient received the medication. The patient survived.
To the patient and me, the process felt like an hour. I understood the decision to keep the medication in the pharmacy as this medication is seldom used on each floor. Stocking each floor could create medical waste. In years past, I would have been able to grab the medicine and give it myself if needed. But that brings its own inherent risks (stocking, expiration dates, a physician administering a medicine normally administered by a nurse, etc.).
In summary, as we build systems to be more robust and safe, let's not forget that the extra steps in the process may very well slow us down and may possibly have worse outcomes. Being proactive by including clinicians and health informaticians in the research, development, and implementation of such products is key.
Jonathan S. Ware, MD
Thursday, August 6, 2009
Pen, Paper, AND Computer?
Research scientist in Indianapolis have discovered that using a pen and paper in conjunction with an electronic medical record prove useful says an article in HealthcareITNews.com.
It seems that being 100% electronic may not be as efficient as originally thought. In fact, the number one reason for using a paper and pen as a workaround was efficiency and ease of use. Another common reason was as a memory aid.
Something that caught my eye was the third most common reason for using a paper and pen as a workaround: alerts. With all of the icons and things to click on a screen, how easy is it to miss an alert? If the alerts are 'soft stops' and can be clicked through without taking an action, then what is to prevent someone from becoming click happy and missing an important alert?
In this era of transition to fully computerized health records, maybe having a pen and paper handy isn't so bad after all.
Jonathan S. Ware, MD
It seems that being 100% electronic may not be as efficient as originally thought. In fact, the number one reason for using a paper and pen as a workaround was efficiency and ease of use. Another common reason was as a memory aid.
Something that caught my eye was the third most common reason for using a paper and pen as a workaround: alerts. With all of the icons and things to click on a screen, how easy is it to miss an alert? If the alerts are 'soft stops' and can be clicked through without taking an action, then what is to prevent someone from becoming click happy and missing an important alert?
In this era of transition to fully computerized health records, maybe having a pen and paper handy isn't so bad after all.
Jonathan S. Ware, MD
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