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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...


  1. Hi Bobby, you raise an interesting point. Structured data entry can be very time-consuming, so it is not unreasonable to see it as a problem in some instances. However, like all things, results vary. I have been involved in EHRs since the 1990s when physicians bought systems without incentives. Many of them wanted templates, especially to improve E&M coding reimbursement. Fact is, not all templates are the same. Some are poorly designed, others not.

    The effects of MU on interface/template design cannot be overlooked. In trying to keep up with cert requirements, vendors kludged new data requirements onto interfaces. Further, many vendors do not offer screens that vary by specialty.

    EHR design has moved from where a narrative was the norm 20 years ago, with templates used for specific patients (say for diabetes tracking), to a number of quality improvement efforts today with greater data requirements. Some EHR designers handle this better than others. The ultimate question is: What role poor design plays in data entry misery? I would like to see more experimentation in ways to capture structured data. The extremes now are filling out on-screen forms on one hand, and the quest for natural language processing/machine learning on the other. There must be a middle ground. Perhaps a clinical markup language, or limiting structured data capture to specific conditions or patients instead of every patient.

    In addition, it is not clear to me how useful routinely collected data, structured or otherwise, is for research or other analytical purposes. Sure, one can collect data, but what reality do those data actually represent? Data quality in EHR systems varies greatly, even worse there are no formal metrics for defining data quality.

    Weiskopf NG, Weng C. Methods and dimensions of electronic health record data quality assessment: enabling reuse for clinical research. J Am Med Inform Assoc. 2013 Jan 1;20(1):144-51.

    Köpcke F, Trinczek B, Majeed RW, Schreiweis B, Wenk J, Leusch T, Ganslandt T, Ohmann C, Bergh B, Röhrig R, Dugas M, Prokosch HU. Evaluation of data completeness in the electronic health record for the purpose of patient recruitment into clinical trials: a retrospective analysis of element presence. BMC Med Inform Decis Mak. 2013 Mar 21;13:37.

    At my last visit, my doctor said he would avoid using the EHR because it got in the way. So, how much of what clinicians hate is bad design, versus a bad idea (.i.e., this should be computerized at all)? I have no idea, but I’m working on it…

    Jerome Carter, MD

    1. Thank you, Dr. Carter. Great observations.

      "it is not clear to me how useful routinely collected data, structured or otherwise, is for research or other analytical purposes."

      Well, my example here of MU "Smoking Status" acutely begs that very question. As clunky a metric set as it is, you'd think we'd have seen some CMS aggregate tabulations by now. Maybe it's just as well. The snazziest MU Core 9 crosstabs in the world will not tell us anything we don't really already know.

      When I first started in health care analytics in 1993 for one of the Medicare "PROs" we were able to extract a good bit of value from simple old "HCFA" UB-82 claims data sets. You would think that actual structured CLINICAL data emanating from EHRs would be even more worthy. Back then we had to send out teams of nurse abstractors lugging laptops to go to indicated facilities and cull clinical data from the charts.

      That aside, the beef as set forth by Margalit and HIT critics more broadly is that such data don't add any value to the patient visit and only serve to interfere with an already too busy interval of time in the exam room. Again, that's a mix of UX suboptimality and "productivity treadmill" imperatives.