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Wednesday, December 30, 2015

Health IT, adieu 2015, accueillir 2016

Been an interesting year. Lots of chatter (ranging from the euphorically optimistic to the contentious, cynical, and bitter), less in the way of actual, well, "transformation" (Recall "Free Beer Tomorrow?")

I've been distracted a good bit in 2015 by my own interaction with the "shards" of our healthcare "system" from the patient's POV. Finished up two months of daily Calypso radiation treatment in November, and, in the wake of my first follow-up with my oncologist, looks like I'm good to go. Now I just gotta get back in shape. To that end, we bought a fancy NordicTrack rowing machine, and I've started giving it my Frank Underwood best.

~240 calories an hour? Jeesh...

2015 started with a flourish for me via the inaugural Health 2.0 "WinterTech Conference" in January. Also extremely noteworthy early on, "Announcing the launch of Dr. Jerome Carter's Clinical Workflow Center."

The mid-year "Healthcare Lean Transformation Summit 2015" in Dallas was definitely a KHIT highlight. Progressive, effective process QI is alive and well. I'm going to the 2016 Summit in Miami. Dr. Toussaint told me "bring your axe."

I ended my conference coverage year at Health 2.0 2015 in Santa Clara. See here, here, here, and here. It was problematic, given that I had to bail mid-day every day to run up the freeway to Pleasant Hill for radiation tx.

Spent a lot of time in 2015 ruminating on the dx/tx implications of "The Omics," study that will no doubt continue and deepen. You have to worry about Gartner Hype Cycle stuff there.

Also of ongoing interest, "artificial intelligence (AI) and intelligence augmentation (IA)" and their implications for medical science and health care. See "AI vs IA: At the cutting edge of IT R&D."

Of course, there're also the usual: Health IT "usability"/UX, workflow, the beleaguered Meaningful Use program, "Interoperababble," healthcare workforce culture, clinical pedagogy, and so forth.


From THCB:

Health 2.0 Presents the Final Agenda for WinterTech 2016

Health 2.0 announces the final agenda for the WinterTech conference, January 13, 2016 in San Francisco, California. As the only event dedicated to health tech and investing during the health investment mecca, JP Morgan Week, the event features leaders from Venrock, Canvas, Grand Rounds, Doximity, Livongo, Omada Health, Maverick Capital, GE Ventures, Kaiser Permanente and more. The conference brings together top health tech entrepreneurs, investors, and the health care establishment to discuss financial and business trends. “Everyone knows by now that health tech is a hot place for venture investing,” says Health 2.0’s Co-Founder Matthew Holt. “At Health 2.0 WinterTech, we are going to uncover the secrets of how the top VCs think and how they work with the star CEOs.” Key speakers will include:

  • Vinod Khosla: Founder, Khosla Ventures. Vinod will discuss his thoughts on the digital health care space, his investments, and more with Health 2.0 CEO & Co-Founder, Indu Subaiya.
  • Bryan Roberts: Partner, Venrock. Known as the original digital health VC, Bryan has made a lasting impact in the health care landscape. Health 2.0’s Co-Founder Matthew Holt will have a one-on-one with Bryan to address what investing in digital health really means.
  • Jonathan Bush: CEO and Co-Founder, athenahealth. A firm believer in creating a marketplace that allows the unlimited and effective exchange of health information, Jonathan is set to keynote at this year’s conference.
With sessions addressing New Clinical Tools and Platforms, the Convergence of Life Sciences and Health Tech, the New Consumer Health Ecosystem and more, other speaker highlights include:
  • Owen Tripp, CEO, Grand Rounds
  • Glen Tullman, CEO, Livongo Health
  • Sean Duffy, CEO, Omada Health
  • Rebecca Lynn, Co-Founder & Partner, Canvas
  • Jeff Tangney, CEO, Doximity
  • Joan Kennedy, VP Consumer Health Engagement, Cigna
  • John Mattison, CMIO, Assistant Medical Director, Kaiser Permanente
  • Peter Ohnemus, President & CEO, dacadoo
  • Jody Holtzman, SVP, AARP
  • Ruchita Sinha, Director, GE Ventures
  • Ankur Luther, Executive Director, Morgan Stanley
  • David Duncan, Co-Founder & CEO, Arc Programs
  • Carolyne Zimmermann, Partner, Novartis dRx Capital
  • Ambar Bhattacharyya, Managing Director, Maverick      Capital
  • Dave Francis, Managing Director, RBC Capital Markets
… Plus over 20 more speakers including live product demos.
Health 2.0 is famous for its incredible selection of LIVE demos, and this year you’ll see:
  • Redox
  • Lyra Health
  • Accordion Health
  • Bigfoot Biomedical
  • Outset Medical
  • dacadoo
  • Propeller Health
  • LifeQ
  • physIQ
An exclusive Investor Breakfast is open to attending startups looking to discuss business models, examine trends, and explore portfolios before the mainstage kickoff. This year’s investors include Norvartis dRx Capital, Maverick Capital, Sandbox, Ziegler, HealthBox, Link-age Ventures, Arsenal Venture Partners, and more. Apply to attend by submitting your application here.

Learn more about the agenda here and visit the registration website to attend. We were sold out last year so buy your tickets soon!

About WinterTech

Through fireside chats, interviews, and compelling panel discussions, Health 2.0’s WinterTech brings together historically distinct industries in health to challenge the current landscape and push it towards an environment that is user driven, informed, and financially profitable for all players involved.
The VC/capital investing thing will be of particular personal interest this coming year. My Niece's husband Jeff Nyquist, who holds a Vanderbilt PhD in neuropsychology, is launching a startup.

The initial focus will be on virtual reality cognitive training for elite athletes, both for improving aggregate performance and for reducing the risk of injury -- particularly concussion injuries (now much in the news).

I watched an interesting interview yesterday featuring writer Gregg Easterbrook on the topic of concussion injury in football.

He noted that, while all of the media attention is focused on the NFL, a huge wave of brain injury litigation is coming at the high school level, and may well wipe out many high school football programs -- which, of course, feed the NCAA "farm league" system that in turn feeds the NFL.

In addition to collision-mitigating rule changes, perhaps "neural training" can be beneficial.

HIMSS 2016

HIMSS returns to Vegas.

There are not many cities with sufficient convention capacity to accommodate HIMSS. Won't be a problem in Vegas. I've again applied for a "social media ambassador" press pass. This, if granted, will be my 4th trip to HIMSS on a media comp, beginning with the 2012 Conference in Vegas.

This should be interesting, in light of current news.

Hope he's clean. Unfortunate timing for HIMSS.


Relatively quiet on the fragmentation front at the moment. All I have are intermittent follow-ups in 2016. We've decided to jettison the BCBS/RI high-deductible HSA coverage in favor of straight Medicare A and B (and including Part-D Rx coverage and a MediGap Part-B Supp). My wife's employer notified them of pending large premium increases for 2016. We'd not known it, but her company is "self-insuring." The bumbling, obstructive BCBS/RI merely serves as their Plan Administrator. Gilbane doesn't have a big enough risk pool, and their 2015 claims loss experience has squeezed them big-time.

Medicare B/D/Supp won't be "free," but at least they will comprise "first-dollar coverage" (to a degree) and be pretty much a net wash in terms of monthly premium outlay (a lot of this stuff is not really "insurance," anyway, it's 3rd-party intermediated "pre-payment").

Interestingly, I went to the "Covered California" website and did some coverage searching. The "silver" plans were all just below $900 per month for someone like me. My total personal Medicare premium outlay, in contrast, will be on the order of $207 per month.

I'm now fully a Medicare "bene." My wife will be shortly as well once she finishes her Part-D and MediGap Supp apps.

More to come...

Thursday, December 24, 2015

All I have to say about Pharma Bro'

From a comment I posted under one of the myriad articles on the hated hedge fund speculator Martin Shkreli.

Read the Indictment, 29 page pdf. I have it. Not one word about drug pricing. He’ll eventually be Pleading for some relatively soft time in a Club Fed. Probably have to spend some of whatever money he has left for one of those "Successfully-Coping-With-Your-White-Collar-Prison-Time" consultants. Whatever this sorry episode tangentially, inferentially “says” about the  corrupt Pharma world is utterly beside the point. This kid is just an arrogant boiler room grifter, a poseur Master-of-the-Universe Madoff wannabee (and a laughable repeat failure at that) who’d have tried to pull the same crap with companies in other business lines were he focused on them.

Beyond the indictment specs, read up on his KaloBios CusterFluck. Boy, THAT was a short CEO & Board Chair hostile takeover tenure (all of about 5 weeks).

Don’t hold your breath for a Michael Lewis book and movie about this loser (It would have to be titled "The Femto Short"). He won’t even merit a Vanity Fair article.
Shkreli, proudly wearing his Bad Boy arrogance on his sleeve, had dismissively claimed that his raising of the price of Daraprim by some 5,000% after he'd acquired the distribution rights was necessary to provide R&D funding for new lifesaving drugs in his Turing Pharmaceuticals company. So, his first big move thereafter? A hostile takeover of the moribund Bay Area KaloBios Pharmaceuticals, whereupon he had himself installed as CEO and Board Chairman.

KaloBios' most valuable asset? Not a lifesaving drug, not scientific staff expertise, but a fungible FDA regulatory waiver that could be sold to the highest bidder.

Given that he acquired KaloBios using OPM (Other Peoples' Money), he will surely be spending many years at the Defendant's tables in civil courts in addition to his criminal problem, now that this investment is in the toilet (KB stock has again cratered and NASDAQ has delisted them after having halted KB trading). His lengthy track record of losing OPM (since his very first hedge fund initiative) will do more to permanently ostracize him among the investment community than any of his juvie social media antics.

Hope it was fun while it lasted, son.

Monday, December 21, 2015

Clinician "burnout." Is HIT a significant factor?

Google "physician burnout" (with quotation marks around the phrase to optimize the findings). Similarly, Google "nurse burnout" as well. Roughly 109,000 and 56,700 search results, respectively this morning.

Not exactly news. When I first came to health care in 1993 for my first of three stints with HealthInsight (at the time known as "Nevada Peer Review"), most of our staff were astute, experienced RNs, who were often referred to as "floor burnout cases."

Back then, there was HIT, but it was mostly administrative/ops "big iron" in the hospitals and fledgling local "PMS" ("Practice Management Systems") in the ambulatory settings. Paper charts were the near-exclusive norm. Workforce cultural "burnout" inducing psychosocial toxicity existed back then as well.

Has the widespread adoption of full-blown Health IT made things worse? (apropos of my lengthy prior post.)

A new Mayo study (pdf) has been published and reported, focused on physician burnout.

Medicine is both a demanding and a rewarding profession. Physicians spend more than a decade in post-secondary education, work substantially more hours than most US workers in other fields, and often struggle to effectively integrate their personal and professional lives. They engage in highly technical and intellectually demanding work that often requires complex, high-stakes decision making despite substantial uncertainty. These challenges are offset by meaningful relationships with patients, the intellectual stimulation of the work, and the satisfaction of helping fellow human beings. Physicians are also well compensated relative to many professions, are part of a fraternity of supportive colleagues, and often enjoy the respect and appreciation of their community.

The cumulative effect of these forces on the personal and professional satisfaction of each physician is unique. Although future physicians begin medical school with mental health profiles better than those of college graduates pursuing other fields, this profile is reversed 1 to 2 years into medical school. Once in practice, physicians have generally high degrees of satisfaction with their career choice but experience high degrees of professional burnout and dissatisfaction with work-life integration. Burnout is a syndrome of emotional exhaustion, loss of meaning in work, feelings of ineffectiveness, and a tendency to view people as objects rather than as human beings. Burnout has profound implications for individual physicians and their families. In addition, burnout appears to impact the quality of care physicians provide and physician turnover, which have profound implications for the quality of the health care delivery system...
Well, if you trouble yourself to study the entire paper, this is all you will find alluding to Health IT:
The landscape of medicine continues to rapidly evolve. Technology, legislation, and market forces have contributed to consolidation of medical practices, fluctuating reimbursement, new care delivery models, increased productivity expectations for physicians, and more widespread use of electronic medical records over the past several years.

Page 1601.

So, the problem is widespread and growing, but...
What are the possible solutions to this problem? More than 75% of the physicians are now employed by large health care organizations and meaningful progress will require an effective response at both the individual level and the organization or system level. Health care organizations should focus on improving the efficiency and support in the practice environment. [pg. 1608] 
Oh, boy, "improving efficiency."

More recommendations.
  • select and develop leaders with the skills to foster physician engagement;
  • help physicians optimize "career fit;"
  • create an environment that nurtures community, flexibility, and control, all of which help cultivate meaning in work;
  • establish principles that help facilitate work-life integration;
  • help physicians self-calibrate and promote their own wellness.

Anyone see any issues here?

Relatedly, it's not just about the physicians. Recall from my prior post:

From The NY Times:
When Hospital Paperwork Crowds Out Hospital Care

A FRIEND was recently hospitalized after a bicycle accident. At one point a nursing student, together with a more senior nurse, rolled a computer on wheels into the room and asked my friend to rate her pain on a scale of 1 to 10.

She mumbled, “4 to 5.” The student put 5 into the computer — and then they left, without further inquiring about, or relieving, my friend’s pain.

This is not an anecdote about nurses not doing their jobs; it’s an illustration of what our jobs have become in the age of electronic health records. Computer documentation in health care is notoriously inefficient and unwieldy, but an even more serious problem is that it has morphed into more than an account of our work; it has replaced the work itself...
 Read all of it. Again, to what extent is HIT implicated in "burnout"?

Stay tuned.

More to come...

Sunday, December 13, 2015

Are structured data the enemy of health care quality?

Are structured data now the enemy of health care quality?

Margalit apparently thinks so. Per my last post, which was an annotated analytical cross-post of Margalit Gur-Arie's provocative post "Bingo Medicine," which was itself first cross-posted at THCB.
the one foundational problem plaguing current EHR designs – the draconian enforcement of structured data elements as means of human endeavor...

People don’t think in codified vocabularies. We don’t express ourselves in structured data fields...
Furthermore, when your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say...
"Draconian enforcement." Gotta love that.

So, is digital health IT is inimical to clinical acumen, and consequently, patient outcomes? This was red meat for the resident naysayers who frequent THCB's comment boards.
"Nice post, Margalit. You’ve done an excellent job describing the implosion caused by EHRs at ground zero—the clinician/patient relationship. The collateral damage has been horrific too. Expert docs retiring prematurely, billions of dollars wasted, serious errors made by trusting the EHR info, significant drag on health care productivity. It may take the perspective of a generation to fully comprehend the disaster."
"Meaningful use is like a straight jacket on the practice of medicine. Its removal will help HIT to flourish."
"The source of the EHR damage to the doctor patient relationship and the fiscal damage to our health care system was HiTech incentives (CMS “These incentive payments are part of a broader effort under the HITECH Act to accelerate the adoption of HIT and utilization of qualified EHRs.”

Without these incentives EHR’s would likely have developed in a manner in which they were helpful to physicians and not encumbered with all the population management and administrative bells and whistles that most “thought leaders” love.

A necessary step in correcting the EHR disaster must include ending the Hitech incentives/subsidies… unlikely to happen until after the 2016 Presidential election."
"You say, “The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.” But you imply that there will be clinically meaningful clicks in our future when self-appointed thought leaders learn to digitize the multivariate, interactive, inexact, unreliable and temporally varying factors that comprise the idiosyncratic predicaments of life. Really? Ever?" [Nortin Hadler, MD]
“The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.”

Well, OK, but, having worked in the Meaningful Use program at one of the RECs (wherein I routinely bit the sometimes bozo hand that fed me), I can only note with confidence that everyone had substantive input on the MU regs at every step. The public review and comment repositories routinely overflowed with thousands of recommendations (even after culling the Kenyan Commie Obama Healthcare Dictatorship ones), many of them written by physicians working daily in the clinical trenches. Rational and practicable recommendations got incorporated. ONC and CMS listened. And, repeating thoughts from my last post,
surveying docs as to their opinions on documentation and digital decision support can be done, and has been done, repeatedly. As with nearly all opinion polling, you get wide distributions of sentiment pro and con. Moreover, all of this latest naysaying misses one fundamental point. It's not about information technology per se, it's the "productivity treadmill" imperative. If the typical physician only had to see an average of one patient per hour (8-10 pts per day) rather than 25-30, adequate documentation would be way less onerous. Let the mids handle the banal cases.
Unless you're really arguing that physicians should be absolved from any documentation duties whatsoever.
What proportion of patient encounter bookings requiring MD attention are scheduled mainly to keep the doors open? By some credible estimates it's more than half.

Machine-readable (and machine-malleable) alphanumerics, basically. Data that can be readily and quickly entered, recalled, updated, trended, evaluated (given their being also human-readable), and transported for specialty / continuity of care, administrative requirements, and the gamut of analytics.

The latter two uses, of course, being the target of ire by myriad critics, given that they are asserted to have "nothing to do with patient care."
The typical ambulatory EHR, as I have noted before, houses perhaps 4,000 variables within its RDBMS. A typical moderately complex patient encounter may require attending to several hundred of them in a half-hour or less. It's not viable.
I will be the first to admit that some of the MU criteria are simply stupid. to wit:

From my Clinic Monkey spoof site:

Yeah, I know, they added two more drop-down response options for Stage 2, but it's still absurd, pretty useless. The handful of workflow seconds devoted to querying and compliantly recording this MU Core 9 Measure are a waste of valuable time, particularly given that most full-featured EHRs provide much more granular, detailed categorical, ordinal, and quantitative response options for this one health parameter.

Perhaps optimal "health care quality" requires the open-ended analytical narrative in the progress note, replete with evocative, dx-illuminating metaphors and analogies and elegant turns of phrase in lieu of blunt instrument categorical and ordinal "structured data." That whole elusive "Art of Medicine" thing. The "Spaces Between the Facts comprising 'Big Data'." The slow, contemplative Medicine of "God's Hotel." Listen. look, palpate, empathize...

e.g., an "empathic" social history self-report follows. Retired surgeon and author Richard Selzer, MD:


What some people will not do to assure themselves that they exist! A woman dabs her neck with perfume, then walks abroad. In the sensible cloud of droplets about her, she has created an extension of her corporeal self, and of her personality, too. With each inhalation, that which she may have but vaguely suspected, her being, is most indisputably confirmed. I am here, she sniffs happily. I am really here.

And whistlers. Even the air-hungriest asthmatic who has not the least idea where to place his pitch or tone, who plays blindman’s buff with melodies no more intricate than Mary Had a Little Lamb, even such a one as this will walk the earth, lips pursed to a fine aperture, an expression of distraction upon his face as though he had just seen a vision. All the while from his feeble reed there issues a toneless beeping, a sorry complaint. It does not matter that the music he makes will not enter the living repertoire. No special color identifies it as baroque, flamenco, or twelve-tone; it is all of these and none of these. All about his head the whistler draws his helmet of sound. It is a private affair. Blowing out, he directs his notes within. The whistler himself but half attends the noise he makes. It is enough. He listens, and knows beyond all evidence to the contrary that he is there. His presence cannot be denied.

Thus do tenors and tuba players alike take the deep breath, set the vocal cords just so, and blast forth the good news of their existence. So, too, the child who climbs to the top of the slide, sits down, and makes ready to plummet. At the last moment he pauses, calls out to his mother. “Watch me!” he cries. And in her face he reads the success of his advertisement: Here I am.

I myself do it by smoking. And let no meddlesome man caution me against the extravagance, the injuriousness, of tobacco. I am addicted in a way more fundamental than any mere physiological craving. To deny me my smoke is to extinguish me as utterly as would death itself. It is to butt me into cold ashes.

Consider the act of smoking. It is constituted, is it not, of inhalation and exhalation? To draw deeply upon a cigarette, to fill the tracheobronchial tree with smoke, is to feed an empty space deep within, a space that twenty times a day cries out for appeasement. As nature abhors a vacuum, so does that cavern yearn for repletion. Should it, by some unhappy circumstance (you have run out of cigarettes in the dead of night), remain empty for too long a time, then the yearning becomes palpable. There is discomfort. The hollowness becomes an ache. One may perish of it.

I am not so vain, nor so uniquely neurotic, as to believe that I am alone in the world with such a hungry hole, a pit in search of something to enclose. Nor will mere fresh air suffice. For this interior sack is no mere biology, but an urbane bag for whom taste has been deliciously refined. It needs smoke. And smoke it shall have. Smoke is, after all, little enough. Time was when a man could, with the forthrightness of a child, enjoy a healthy expectoration, the passage of some audible flatus, or the scratching of his personals. But civilization has come to mean the narrowing down of what we are permitted to do in public. Little BoPeep has gone away, and in her place the Iron Maiden of Etiquette shepherds us toward good deportment.

Smoking is good for the dumpish heart; lights up the gloomies, don’t you know? Let the innumerable sad circumstances of humiliations past, of stumbles yet to come, crowd in upon me; then, out of the night that covers me, I grope for that thing with which to tampon the leak in my soul. All at once there is the scratch of a match. A pretty flame breaks. It swings to the touch. Ignition! And there blows a very wind from paradise.

There are circuits in the brain and lung that are triggered by the shifting of gases in the blood. So goes our soughing: at the end of exhalation there is a small but measurable rise in the level of carbon dioxide. This is noted by the respiratory center of the brain. The order is issued to the lung: inhale. Oxygen is taken in, the carbon dioxide level falls. In a moment it will rise again. Now: exhale. The muscles of expiration, those strips of meat between and overlying the ribs, are commanded to contract. They close in upon the chest cage, compressing it. The leaves of the diaphragm billow upward, further encroaching upon the lungs, which twin sponges are squeezed toward the trunk of the windpipe.

The larynx, too, assumes a posture, its little muscles squeezing to hold open the glottic chink at the top of the trachea to let out the smoke. Aah ... and out it comes, now a slow-blown wisp, now a fat cloud. It rises about the face. That which was a moment before deep within pours to the out-of-doors, the soul come punctually visible. See it diffuse, coiling fainter and fainter into the general atmosphere. Here is proof— one needs no more— you exist, are here, because smoke, that gaseous testimony, is there.

One is. This smoke is the ultimate assurance.

Here I am, I say to myself ... and take another puff. It’s me.

Selzer, Richard (1996-04-15). Mortal Lessons: Notes on the Art of Surgery (Harvest Book) (Kindle Locations 1608-1646). Houghton Mifflin Harcourt. Kindle Edition.

How's that for first-person ("subjective" component of the SOAP) Social History nuance?
BTW, I had some Lucky Strikes while in the 5th grade in Hanover NJ that cured me for life.
That was written more than 4 decades ago (and is by now as non-"PC" as Skinner at Harvard). It's a telling commentary to me regarding the decline of American letters that the likes of Atul Gawande is considered today's literary eminence of medical writing.

BTW, another of my literary heroes, former Harpers editor Lewis Lapham on smoking.

More Selzer here: The Corpse. Also, Dr. Selzer on Yoshi Dhonden, personal physician to the Dalai Lama.


...when your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template...
Well, I certainly could be wrong, but, I have to be a bit skeptical that that is anything more than a motivated-reasoning assertion of opinion lacking evidentiary underpinning comprised of adequate psychometrically valid studies of physicians' cognitive processes while at work, perhaps using docs on paper charts as the differential "control" group. Moreover, every EHR I have worked with (dozens) has come with ample "free text narrative" functionality accessible from myriad workflow locations (along with Dragon-enabled voice transcription), and, to the extent that such functionality is insufficiently utilized, such -- again -- may well be as much shaped by business imperative "productivity treadmill" drivers as any adverse cognitive shaping wrought by EHR templating and structured data entry and management.

Again, I could be wrong. I will certainly run that thought past Jerome Carter, MD at EHR Science. I'll also have to re-visit the work of Dr. Jerome Groopman ("How Doctors Think") and Dr. Bob Wachter ("The Digital Doctor") and various others on the issue.

apropos, see, e.g., my October 14th post "Health IT, the data, the dx, the dogs of uncertainty, and the miners' dig that is your digital life."


A bit of exhumation reveals this. Some credible countervailing concerns I'd forgotten to recall, consider, and cite.

THE INTRODUCTION of automation into medicine, as with its introduction into aviation and other professions, has effects that go beyond efficiency and cost. We’ve already seen how software-generated highlights on mammograms alter, sometimes for better and sometimes for worse, the way radiologists read images. As physicians come to rely on computers to aid them in more facets of their everyday work, the technology is influencing the way they learn, the way they make decisions, and even their bedside manner.

A study of primary-care physicians who adopted electronic records, conducted by Timothy Hoff, a professor at SUNY’s University at Albany School of Public Health, reveals evidence of what Hoff terms “deskilling outcomes,” including “decreased clinical knowledge” and “increased stereotyping of patients.” In 2007 and 2008, Hoff interviewed seventy-eight physicians from primary-care practices of various sizes in upstate New York. Three-fourths of the doctors were routinely using EMR systems, and most of them said they feared computerization was leading to less thorough, less personalized care. The physicians using computers told Hoff that they would regularly “cut-and-paste” boilerplate text into their reports on patient visits, whereas when they dictated notes or wrote them by hand they “gave greater consideration to the quality and uniqueness of the information being read into the record.” Indeed, said the doctors, the very process of writing and dictation had served as a kind of “red flag” that forced them to slow down and “consider what they wanted to say.” The doctors complained to Hoff that the homogenized text of electronic records can diminish the richness of their understanding of patients, undercutting their “ability to make informed decisions around diagnosis and treatment.”

Doctors’ growing reliance on the recycling, or “cloning,” of text is a natural outgrowth of the adoption of electronic records. EMR systems change the way clinicians take notes just as, years ago, the adoption of word-processing programs changed the way writers write and editors edit. The traditional practices of dictation and composition, whatever their benefits, come to feel slow and cumbersome when forced to compete with the ease and speed of cut-and-paste, drag-and-drop, and point-and-click. Stephen Levinson, a physician and the author of a standard textbook on medical record keeping and billing, sees extensive evidence of the rote reuse of old text in new records. As doctors employ computers to take notes on patients, he says, “records of every visit read almost word for word the same except for minor variations confined almost exclusively to the chief complaint.” While such “cloned documentation” doesn’t “make sense clinically” and “doesn’t satisfy the patient’s needs,” it nevertheless becomes the default method simply because it is faster and more efficient— and, not least, because cloned text often incorporates lists of procedures that serve as another trigger for adding charges to patients’ bills.

What cloning shears away is nuance. Nearly all the contents of a typical electronic record “is boilerplate,” one internist told Hoff. “The story’s just not there. Not in my notes, not in other doctors’ notes.” The cost of diminished specificity and precision is compounded as cloned records circulate among other doctors. Physicians end up losing one of their main sources of on-the-job learning. The reading of dictated or handwritten notes from specialists has long provided an important educational benefit for primary-care doctors, deepening their understanding not only of individual patients but of everything from “disease treatments and their efficacy to new modes of diagnostic testing,” Hoff writes. As those reports come to be composed more and more of recycled text, they lose their subtlety and originality, and they become much less valuable as learning tools.

Danielle Ofri, an internist at Bellevue Hospital in New York City who has written several books on the practice of medicine, sees other subtle losses in the switch from paper to electronic records. Although flipping through the pages of a traditional medical chart may seem archaic and inefficient these days, it can provide a doctor with a quick but meaningful sense of a patient’s health history, spanning many years. The more rigid way that computers present information actually tends to foreclose the long view. “In the computer,” Ofri writes, “all visits look the same from the outside, so it is impossible to tell which were thorough visits with extensive evaluation and which were only brief visits for medication refills.” Faced with the computer’s relatively inflexible interface, doctors often end up scanning a patient’s records for “only the last two or three visits; everything before that is effectively consigned to the electronic dust heap.”

A recent study of the shift from paper to electronic records at University of Washington teaching hospitals provides further evidence of how the format of electronic records can make it harder for doctors to navigate a patient’s chart to find notes “of interest.” With paper records, doctors could use the “characteristic penmanship” of different specialists to quickly home in on critical information. Electronic records, with their homogenized format, erase such subtle distinctions. Beyond the navigational issues, Ofri worries that the organization of electronic records will alter the way physicians think: “The system encourages fragmented documentation, with different aspects of a patient’s condition secreted in unconnected fields, so it’s much harder to keep a global synthesis of the patient in mind.”

The automation of note taking also introduces what Harvard Medical School professor Beth Lown calls a “third party” into the exam room. In an insightful 2012 paper, written with her student Dayron Rodriquez, Lown tells of how the computer itself “competes with the patient for clinicians’ attention, affects clinicians’ capacity to be fully present, and alters the nature of communication, relationships, and physicians’ sense of professional role.” Anyone who has been examined by a computer-tapping doctor probably has firsthand experience of at least some of what Lown describes, and researchers are finding empirical evidence that computers do indeed alter in meaningful ways the interactions between physician and patient. In a study conducted at a Veterans Administration clinic, patients who were examined by doctors taking electronic notes reported that “the computer adversely affected the amount of time the physician spent talking to, looking at, and examining them” and also tended to make the visit “feel less personal.” The clinic’s doctors generally agreed with the patients’ assessments. In another study, conducted at a large health maintenance organization in Israel, where the use of EMR systems is more common than in the United States, researchers found that during appointments with patients, primary-care physicians spend between 25 and 55 percent of their time looking at their computer screen. More than 90 percent of the Israeli doctors interviewed in the study said that electronic record keeping “disturbed communication with their patients.” Such a loss of focus is consistent with what psychologists have learned about how distracting it can be to operate a computer while performing some other task. “Paying attention to the computer and to the patient requires multitasking,” observes Lown, and multitasking “is the opposite of mindful presence.”

The intrusiveness of the computer creates another problem that’s been widely documented. EMR and related systems are set up to provide on-screen warnings to doctors, a feature that can help avoid dangerous oversights or mistakes. If, for instance, a physician prescribes a combination of drugs that could trigger an adverse reaction in a patient, the software will highlight the risk. Most of the alerts, though, turn out to be unnecessary. They’re irrelevant, redundant, or just plain wrong. They seem to be generated not so much to protect the patient from harm as to protect the software vendor from lawsuits. (In bringing a third party into the exam room, the computer also brings in that party’s commercial and legal interests.) Studies show that primary-care physicians routinely dismiss about nine out of ten of the alerts they receive. That breeds a condition known as alert fatigue. Treating the software as an electronic boy-who-cried-wolf, doctors begin to tune out the alerts altogether. They dismiss them so quickly when they pop up that even the occasional valid warning ends up being ignored. Not only do the alerts intrude on the doctor-patient relationship; they’re served up in a way that can defeat their purpose.

A medical exam or consultation involves an extraordinarily intricate and intimate form of personal communication. It requires, on the doctor’s part, both an empathic sensitivity to words and body language and a coldly rational analysis of evidence. To decipher a complicated medical problem or complaint, a clinician has to listen carefully to a patient’s story while at the same time guiding and filtering that story through established diagnostic frameworks. The key is to strike the right balance between grasping the specifics of the patient’s situation and inferring general patterns and probabilities derived from reading and experience. Checklists and other decision guides can serve as valuable aids in this process. They bring order to complicated and sometimes chaotic circumstances. But as the surgeon and New Yorker writer Atul Gawande explained in his book The Checklist Manifesto, the “virtues of regimentation” don’t negate the need for “courage, wits, and improvisation.” The best clinicians will always be distinguished by their “expert audacity.”

Carr, Nicholas (2014-09-29). The Glass Cage: Automation and Us (pp. 100-104). W. W. Norton & Company. Kindle Edition.
I reviewed this book more than a year (and about 80 books) ago, e.g., "An Epic battle: Did the EHR kill Dallas Ebola patient zero? On the double-edged sword of Health IT."

Well, hmmm... back to the core question: Does digital Health IT actually hurt patient care, as Margalit asserts? Given that we're not going back to paper charting en masse, where does that leave us? What would significantly patient care-enhancing Health IT look like? Will all of the powerful entrenched secondary and tertiary "stakeholders" comprising the documentation tail continue to wag the HIT dog?

"While I will acknowledge that no one really wants to do a lot of these clicking tasks, if the powers that be have, at least for the moment, told us that they need to be done (and we can argue for a long time about whether this really promotes quality care or generates useful data), then we have to find a better way to get them done without burning out our brains.
The electronic health record arrived on scene as a way to help us better document the care we provide for patients, to create a safer and more accurate representation of what went on in the provider-patient interaction. And a bonus of eliminating illegible physician handwriting.

Unfortunately the EHR has become an unwieldy behemoth, a massive lurching pile of documentation in which somehow, somewhere, is perhaps buried some small kernel of the truth of what went on..."

From "Can the EHR Be Our Friend?"

Over the last century, our diagnostic and therapeutic tools have grown enormously, but our means for dealing with them have lagged far behind, leaving doctors overwhelmed and sapped of time, joy, and empathy. If our technology succeeds in helping us manage this information, physicians and other health professionals may find themselves able to return to the fundamental work of medicine: diagnosing, treating, comforting, teaching, and discovering.

Wachter, Robert (2015-04-01). The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (p. 274). McGraw-Hill Education. Kindle Edition.
"Sapped of time, joy, and empathy."

Deep dive into the salient characteristics of "empathy" now in the KHIT oven. Stay tuned.


From The NY Times:
When Hospital Paperwork Crowds Out Hospital Care

A FRIEND was recently hospitalized after a bicycle accident. At one point a nursing student, together with a more senior nurse, rolled a computer on wheels into the room and asked my friend to rate her pain on a scale of 1 to 10.

She mumbled, “4 to 5.” The student put 5 into the computer — and then they left, without further inquiring about, or relieving, my friend’s pain.

This is not an anecdote about nurses not doing their jobs; it’s an illustration of what our jobs have become in the age of electronic health records. Computer documentation in health care is notoriously inefficient and unwieldy, but an even more serious problem is that it has morphed into more than an account of our work; it has replaced the work itself...
 Read all of it.

More to come...

Monday, December 7, 2015

On Health Care Technology: EHR Call-Outs

The always-thoughtful and incisive Margalit Gur-Arie has not posted in a while. But, her new one, "Bingo Medicine," is a doozy. Cross-posting it here, reformatted with my "call-outs" for some emphasis.

It was a dark and stormy night. My computer didn’t catch fire while typing the previous sentence. No alarms were triggered warning me about the quality of such opening. I wasn’t prompted to select subjects and predicates from dropdown lists. I typed the entire sentence, letter by letter, not at all dissimilar to its first rendering back in 1830.
Computer software in general, and Microsoft Word in particular, magically removed the hassles of quills, ink, paper, blotters, sharpeners, ribbons, whiteout, carbon paper, dictionaries, and all the cumbersome ancillary paraphernalia needed to support authoring, but made no attempt to minimize the cognitive effort associated with writing well.
Authoring great literature today requires as much talent and mastery as it did in the days of Edward Bulwer-Lytton.

For several decades, software builders have tried to help doctors practice medicine more efficiently and more effectively. As is often the case with good intentions, the results turned out to be a mixed bag of goods, with paternalistic overtones from the helpers and mostly resentment and frustration from those supposedly being helped.
Whether we want to admit it or not, the facts of the matter are that health IT and EHRs in particular have turned from humble tools of the trade to oppressive straightjackets for the practice of medicine.
Somewhere along the way, the roles were reversed, and clinicians of all stripes are increasingly becoming the tools used by technology to practice medicine.

A common misconception is that EHR designers produce lousy software because they don’t understand how medicine is practiced. The real problem is that many actually do, and the practice of medicine is precisely what they aim to change. These high clerics of disruptive innovation would have you believe that “resistance to change” is equivalent to the resurrection of paper charts, thick ledgers, and medical information coded in secretive hieroglyphs.
The truth is that physicians want to use modern computers, but they resent being used by computers.
And the truth is that if we shed the orthodoxy imposed on us by self-serving “stakeholders”, computer software can indeed help address various problems in health care, some in the here and now, most in a distant future.

One thousand and one elements

This may sound strange to some, but the first step towards putting EHRs back on the right track should be to stop trying to help physicians practice medicine. Clinical decision “support” in the form of alerts, disease specific templates, mandatory checklists, required fields and rigid workflows are some of the things that must be removed from EHRs for two reasons. First, most of these “features” don’t work very well anyway. Second, more often than not, the real purpose of said support is not clinical in nature. For example, alerts about generic substitutes for brand name medications, data fields that must be filled and checkboxes that must be clicked to satisfy billing codes, PQRS or Meaningful Use, and the wealth of screens to be traversed before an order can be placed, have no clinical value. And in most cases the opposite is true.
Some experts argue that EHRs are failing because they are nothing more than an old paper chart rendered on a computer screen.
Many others are outraged by the fabled lack of interoperability (dissemination of information) or the lack of EHR usability, i.e. number of clicks, visual appeal, color schemes and ease of information retrieval. I would suggest that these dilemmas are peripheral to
the one foundational problem plaguing current EHR designs – the draconian enforcement of structured data elements as means of human endeavor.
When Google mapped the Earth, it did not begin by mandating how to build and name roads and buildings. When we indexed and digitized books and articles, we did not require that authors change the way they write prose or poetry. When we digitized music, we did not require composers and performers to produce binary numbers at equidistant time intervals, and we did not make changes to musical instruments to allow for better sampling.  We built our computerized tools to ingest, digest, slice, dice and regurgitate whatever humanity threw at us, without inconveniencing anybody. This is why good technology seems magical.

EHRs on the other hand, are obnoxiously demanding that people change how they think, how they work, and how they document their thoughts and actions, just so that the rudimentary software prematurely thrust upon them can function at some minimal level of proficiency.
People don’t think in codified vocabularies. We don’t express ourselves in structured data fields.
Instead of building computers that elegantly adapt to the human modus operandi, EHRs, unlike all other software tools before them, demand that humanity adjust itself to the way primitive computers work. The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.

All the pretty horses

What is the purpose of EHR documentation templates? There is practically no EHR in use today that does not include visit templates. Visit templates are a list of checkboxes, some with multiple nested levels, which allow documentation by clicks instead of by typing, writing, drawing or dictation. Visit templates are created for each disease and contain canned text for findings judged pertinent to that condition by template creators.
In all fairness, many physicians like documentation templates because with just a few clicks you are able to generate all the documentation required nowadays to get paid for your work, pages and pages of histories, review of systems, physical examination, assessments and plans of care. Do doctors like templates because they believe this extensive documentation is necessary, or do they like templates because the checkboxes alleviate the pain of typing thousands of meaningless regulatory words?
I suspect the latter.

Clinical templates, along with the automated clinical decision support they enable, are advertised as time savers for physicians. The time saved is the time previously spent with patients, and most importantly the time spent thinking, analyzing, and formulating solutions. For most, it’s also the time spent rendering thoughts in a manner that can be understood by another person.
Furthermore, when your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say.
Even in “efficient” practices where staff does the clicking and physicians have the luxury of asking “open ended” questions, the patient story, the quirky details that are irrelevant to the template, are not documented (highlighted, circled, noted on the margins, etc.) anymore. Is this a good thing?

If we proceed on the assumption that IBM Watson and the likes are eventually going to be artificially intelligent enough, and big data are eventually going to be big enough, to respectively analyze and represent a complete human being, then yes, we can safely dispense with old fashioned human expertise. However, we are most certainly not there yet, and regardless of industry rhetoric, we are not certain that we will ever be there, and we are not even sure that we want to ever be there. While this utopia (or dystopia) is portrayed by interested parties as “inevitable”, chances are that for at least several generations we will be forced to contend with imperfect digital renditions of medicine, instead of allowing EHRs to follow the growth of underlying technologies. This is akin to summarily confiscating and shooting all the horses, on the day Henry Ford rolled the first Model T off his assembly line. Where would America be today, if we did that on October 1, 1908?

Furthermore, what type of doctors are we producing when we teach medicine by template, supported by clinical decision aids based on the same template, and assessed by quality measures calculated from template data?
Medicine does not become precise just because we choose to discard all imprecise factors that we are not capable of fitting into a template. Standardization of processes and quality does not occur just because we choose to avert our eyes from the thick edges were mayhem is the norm.
Dumbing physicians down is not the optimal strategy for bringing computer intelligence closer to human capabilities. EHRs should not be allowed to become the means to stifling growth of human expertise, the barriers to natural interactions between people, or the levers pushed and pulled at will by greed and corruption.

Bildungsroman style

Instead, EHRs could be the scaffolding for IMB Watson and other emerging contraptions to grow and become truly useful tools for both doctors and patients, and yes, also for legitimate and beneficiary secondary uses of clinical information.
Instead of mandating that doctors think and work in ways that serve Watson’s budding abilities, we should require that Watson learns how to use the normal work products of humans. Instead of enforcing templated thought and workflows, whether through direct penalties for doctors or indirect certification requirements for software, we should work on teaching Watson how to parse and use human languages in all their complexity.
Watson should grow up to be the multi-media scribe behind the computer screen, the means by which the analog music composed by physician-patient interactions is digitized into zeros and ones without loss of fidelity and without interference with actual performance.

Billions of years of evolution endowed the lowliest human specimen with cognitive abilities that machines will most likely never attain. The glory is in the journey though. We need to accept delayed gratification, and we need to accept that the challenge will span centuries, not just one boom-bust cycle of a fleeting global economy. We need to accept the fact that we will all die long before the ultimate goals are achieved, instead of declaring victory whenever each negligible incremental step is taken. If we are going to create a new form of intelligent life on earth, we need to assume the same humility Nature, or God, has been exercising since the dawn of time and counting.
Otherwise, we are all just a bunch of hacks looking to make a quick buck on the backs of our fellow men and women.


More reflections on this in a bit. For starters, good stuff in the comments over on THCB, where Margalit's post was also put up. From the ever-dour iconoclast Nortin Hadler, MD:
You say, “The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.” But you imply that there will be clinically meaningful clicks in our future when self-appointed thought leaders learn to digitize the multivariate, interactive, inexact, unreliable and temporally varying factors that comprise the idiosyncratic predicaments of life. Really? Ever?
 Yeah, OK, but this is not exactly news, and is really not about charting per se. As I wrote 17 years ago in my essay about my late daughter:
First, the many physicians I have come to know in the past few years are in the main acutely sensitive to the problems of clinical conceit and "paradigm blinders." Indeed, the Utah pediatrician's"$100 bill" wisecrack was offered to an audience of doctors and their allied health personnel during quality improvement training. Second, the body of peer-reviewed medical literature does not constitute a clinical cookbook; even "proven" therapies-- particularly those employed against cancers-- are generally incremental in effect and sometimes maddeningly transitory in nature. The sheer numbers of often fleeting causal variables to be accounted for in bioscience make the applied Newtonian physics that safely lifts and lands the 747 and the space shuttle seem child's play by comparison. Astute clinical intuition is a necessary component of a medical art that must, after all, act and act quickly-- so often in the face of indeterminate, inapplicable, or contradictory research findings.


From The NY Times,
Your New Medical Team: Algorithms and Physicians
Austin Frakt

Can machines outperform doctors? Not yet. But in some areas of medicine, they can make the care doctors deliver better. Humans repeatedly fail where computers — or humans behaving a little bit more like computers — can help. Even doctors, some of the smartest and best-trained professionals, can be forgetful, fallible and prone to distraction. These statistics might be disquieting for anyone scheduled for surgery: One in about 100,000 operations is on the wrong body part. In one in 10,000, a foreign object — like a surgical tool — is accidentally left inside the body.

Something as simple as a checklist — a very low tech-type of automation — can reduce such errors. For example, in a wide range of settings, surgical complications and mortality fell after implementation of a basic checklist including verification of patient identity and body part for surgery, confirmation of sterility of the surgical environment and equipment, and post-surgical accounting for all medical tools. Though simple procedures would all but eliminate certain sources of infections in hospitals, thousands of patients suffer from them in American hospitals every year.

Limits on how much information we can process and manipulate make it hard or impossible for even the smartest and most adept doctors to keep up with new evidence. In 2014 alone, more than 750,000 additional medical studies were published. Granted, a physician might need to keep up only with the evidence in her specialty, but even at a fraction of this rate, it is unrealistic to expect even the best physicians to assimilate every new development in their fields. In cancer alone, 150,000 studies are published annually.

Computers, on the other hand, excel at searching and combining vastly more data than a human. I.B.M.’s Watson — the computer that won Jeopardy! — is among the best at doing so. Teams of physicians at Memorial Sloan Kettering Cancer Center in New York, the University of Texas MD Anderson Cancer Center in Houston, and the Cleveland Clinic are helping to train Watson to apply humanity’s huge store of cancer knowledge to the delivery of more personalized treatment...
I'll cite just 2 comments:
eblair rochester ny
Charles Friedman PhD has framed that the true advances in physician cognitive support is represented by the equation: computer + physician brain > physician brain alone. Larry Weed MD the father the modern Problem-Oriented Record and the SOAP note method also made the point over 40 years ago that physicians cannot only remember all the diagnoses, they cannot remember all the questions to ask each unique patient. The idea of computer assisted decision support is to off load the wrote memory tasks to the computer, which will allow the physician to have more time, not less with the patient. Watson has made progress with looking for "best evidence" or best therapies for unique cancers but the real strides within the area of diagnostic support are happening outside of the media spotlight. The story of doctor being replaced by computer is obviously more attention getting, however computer as cockpit instrument is more realistic and is what is really exciting in healthcare information technology today.
Art Papier MD
Associate Professor of Medical Informatics
University of Rochester
CEO VisualDx


J.M.O'Belly KS
I'm glad I have a doctor who listens to me and then asks questions (and follow-up questions) that actually pertain to me and my health, rather than staring at a screen, reading questions from a script, and typing away in order to qualify my visit for a higher reimbursement level.
Recall from Margalit's thoughts above?
In all fairness, many physicians like documentation templates because with just a few clicks you are able to generate all the documentation required nowadays to get paid for your work, pages and pages of histories, review of systems, physical examination, assessments and plans of care. Do doctors like templates because they believe this extensive documentation is necessary, or do they like templates because the checkboxes alleviate the pain of typing thousands of meaningless regulatory words?
And so it goes. As long-time readers know, I've cited the work of Dr. Larry Weed multiple times.

apropos, coming up soon, more thoughts on "AI/IA." in particular as they pertain to medical science and health care delivery.

From supermarket supply chains to consumer goods to construction to exploring for minerals and oil, the ability to crunch bigger and bigger data sets and make sense of them is improving pretty much every type of human endeavour. Kevin Kelly, the founder of Wired magazine, said the business plans of the next 10,000 startups are easy to predict: “Take X and add AI.” To coin a phrase, blessed are the geeks, for they shall inherit the Earth.

Healthcare is an interesting industry in this respect, because it has so far appeared to lag behind the general trend to improved performance from better information. It has been observed that our healthcare systems are really sick-care systems, often spending 90% of the amount they ever spend on an individual during the final year of their lives. We all know that prevention is better than cure, and that problems are most easily solved when identified early on, but we don’t run our healthcare systems that way.

Two major revolutions are about to sweep across the healthcare horizon, and we will all benefit. One is the availability of small instruments which attach to our smartphones, enabling each of us to diagnose early symptoms of disease, and transmit relevant data to remote clinicians. These instruments are the result of cheaper and better sensors, and the application of AI algorithms and human ingenuity to huge data sets. They will cut out millions of time-consuming and expensive visits to doctors, and enable us to tilt sick-care towards healthcare.

The other revolution is the ability to anticipate and forestall medical problems by analysing our genomes. The Human Genome Project was completed back in 2003, but it soon turned out that although sequencing our DNA was an essential first step to enabling the practical improvements to healthcare we hoped for, it was not enough. We needed to understand epigenetics too: the changes in our cells that are caused by factors above and beyond our DNA sequence. The application of AI algorithms to the data which scientists are generating about gene expression are now bringing those improvements within reach.

There is almost no aspect of life today which is not being improved by artificial intelligence. It is important to bear that in mind as we look at the potential downsides of this enormously powerful technology, and avoid a backlash which could prevent us benefiting from those improvements...

Chace, Calum (2015-08-31). Surviving AI: The promise and peril of artificial intelligence (pp. 38-40). Three Cs. Kindle Edition.
I bought this book in lieu of Nick Bostrom's book Superintelligence: Paths, Dangers, Strategies (for now). I'd first got onto Bostrom via a New Yorker article "The Doomsday Invention: Will artificial intelligence bring us utopia or destruction?"

Relevant to the topic, from THCB, "What Would Issac Asimov Do?"
...As we’ve seen in the medical world–e.g., with regard to robotic surgery, femtosecond lasers, and proton beam therapy–there is an inexorable push to adopt new technologies before we determine that they are safer and more efficacious than the incumbent modes of treatment. Corporations have a financial imperative to push technology into the marketplace, employing the “gee whiz, this is neat” segment of early adopters to carry out their marketing, leading to broader adoption. All this happens well before society engages in the kind of thoughtful deliberation suggested by Eric. Meanwhile those same corporations take advantage of the policy lacunae that emerge to argue for less government interference. Unnecessary harm is done, and then we say, “These things happen.”...

From one of Margalit's comments in a subequent THCB post:
I think Watson type of software should perhaps go to coding school instead of medical school and take care of the drudgery of billing, authorizations, and all the red tape, which can and should be automated. That’s what computers are for.
As to the notion that doctors are in dire need of help with thinking things through and diagnosing, why don’t we do the most basic thing that any developer should do, and ask doctors if they feel incapable of diagnosing disease? Why don’t we ask them if they need help with figuring out what to do after they diagnose something?

We have never posed these questions to physicians (and I will go out on a limb here and say that I think I know what the answer will be). We did however make a unilateral decision to intervene based on opinions from very interested quarters stating that medicine has become too complex for the human mind (or some other cliche along these lines). To me, the reasons behind this decision are suspect, to say the least. But even if I assume good intentions, the reality remains unchanged – we are in the way...
Wow. Well, for one thing, surveying docs as to their opinions on documentation and digital decision support can be done, and has been done, repeatedly. As with nearly all opinion polling, you get wide distributions of sentiment pro and con. Moreover, all of this latest naysaying misses one fundamental point. It's not about information technology per se, it's the "productivity treadmill" imperative. If the typical physician only had to see an average of one patient per hour (8-10 pts per day) rather than 25-30, adequate documentation would be way less onerous. Let the mids handle the banal cases.
Unless you're really arguing that physicians should be absolved from any documentation duties whatsoever.
What proportion of patient encounter bookings requiring MD attention are scheduled mainly to keep the doors open? By some credible estimates it's more than half.

I cannot but help be reminded of the Weeds' book "Medicine in Denial," which I've cited multiple times:
A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.

Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2 1⁄2 trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.

This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about. [Medicine in Denial, pp. 1-2]


By a commenter known as "lawyerdoctor."
With all due respect, Mr. Oram, doctors do NOT “need a lot of help making the right diagnosis.”

Doctors will occasionally benefit from having access to a vast amount of easily retrievable data in order to help confirm a difficult diagnosis. But the overwhelming number of physician decisions made thousands of times every day all over the world are accurate without the assistance of Watson, or Siri, or Medscape, or Oprah. They are made with the assistance of 4 years of medical school, 3-7 years of residency, and many untold years of clinical experience seeing tens of thousands of patients.

It does not help doctors to turn them into data-entry clerks, creating a 17-page electronic documentation stream that serves only to support billing a suture removal as a level 5 ED visit. I went to doctor school, not typing school. I prefer to see patients, talk to them, examine them, and hopefully make them better.

I can assure you that no one will be happier than I to see the day when the “robot doctor” spits out prescriptions for z-paks to runny nosed kids at a kiosk in the mall. Why? Because it means that I don’t have to do it. Will I get paid a little bit less? sure, but I’m fine with that. I can then treat real injuries, serious illnesses, and difficult cases, which is what I was trained in medical school and residency to do. When Watson learns how to put in a chest tube during a trauma code, let me know.
Point taken, to an extent, but might there be just a tad of Straw Man there?


From The Atlantic:
The Unregulated Rise of the Medical Scribe
Demand for note-keepers in doctors’ offices is booming, but standards and training haven’t caught up.

A national campaign for electronic health records is driving business for at least 20 companies with thousands of workers ready to help stressed doctors log the details of their patients’ care—for a price. Nearly one in five physicians now employ medical scribes, many provided by a vendor, who join doctors and patients in examination rooms. They enter relevant information about patients’ ailments and doctors’ advice into a computer, the preferred successor to jotting notes on a clipboard as doctors universally once did.

The U.S. has 15,000 scribes today and their numbers will reach 100,000 by 2020, estimates ScribeAmerica, the largest competitor in the business. After buying three rivals this year, it employs 10,000 scribes working in 1,200 locations...
 OK, beyond the narrow training/competency concern, my comment beneath the article:
I call chart coding "lossy compression." And, in a way, any type of charting documentation is that, whether it's digital "structured data" or handwritten physician narrative impressions in a paper chart. The only way to get at the full contextual clinical encounter would be to videotape it (and then transcribe it -- which would essentially be equivalent to a "deposition" in the legal field). Given that the cost of digital A/V storage capacity is now effectively nil (how many banal YouTube cat vids are out there?), it's technologically possible.

Yes, there would be privacy obstacles to that -- going beyond mere HIPAA.

Maybe we could try it via explicit patient "informed consent opt-in" permission, so we could assess the reliability of scribe charting.

"This encounter may be recorded for quality assurance purposes..."  


My friend Dr. Mike Painter posted this on Facebook.


Apparent campaign strategy? Alienate everyone except Ann Coulter, Cletus, and Billy Bob, Unreal, this guy.

More to come...