[Spam] Re: [IMPROVEDX] Hospital doctors... and other examples of care fractionation and commoditization

Cameron Powell cameron at PHYSICIANCOGNITION.COM
Fri May 13 20:41:46 UTC 2016


One of the deficiencies of EHRs is that without good clinical decision support systems (CDSS) attached, they don’t preserve each team member’s thinking about, among other things, (1) the differential diagnosis and (2) the appropriate workup. So every handoff is a new world, reinventing wheels, missing accumulated institutional knowledge.

We saw another deficiency in the Dallas Ebola case, where the patient’s fever, recorded during a prior visit, *was* in the EHR, but the new ER physician didn’t see it. Having info in the EHR isn't a safeguard; what’s needed are reminders from a good CDSS about what symptoms, signs, or labs to inquire into, based on the inputs already in the system. Only an automated and intelligent CDSS/EHR system can keep key information from falling between the cracks.


Cameron



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> On May 13, 2016, at 2:20 PM, Maureen Cahill <MCahill at NCSBN.ORG> wrote:
> 
> At one time we imagined that the electronic health record would be a likely solution with real-time sharing of meaningful information at every point of care and site of care.
> Maureen
>  
> Maureen Cahill [Associate] 312.525.3646 (D) mcahill at ncsbn.org <mailto:mcahill at ncsbn.org>
> National Council of State Boards of Nursing (NCSBN) 111 E. Wacker Drive, Ste 2900, Chicago, IL 60601-4277 312.279.1032 (F)www.ncsbn.org <http://www.ncsbn.org/>
> Our Mission – NCSBN, Leading in nursing regulation
>  
>  
>  
> From: DR WILLIAM CORCORAN [mailto:williamcorcoran at SBCGLOBAL.NET <mailto:williamcorcoran at SBCGLOBAL.NET>] 
> Sent: Friday, May 13, 2016 2:31 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at list.improvediagnosis.org>
> Subject: Re: [IMPROVEDX] [Spam] Re: [IMPROVEDX] Hospital doctors... and other examples of care fractionation and commoditization
>  
> Involvement of Interfaces
>  
> It is an inescapable fact that harmful outcomes of processes are harmfully affected by harmfully defective interfaces. These include seams, joints, hand-offs, turnovers, shift changes, junctions, transfers, mode changes, sub-tiering, off-referring, divisions of labor, non-interacting records systems, and the like.
>  
> Observation: Change is the mother of trouble.
>  
> Observation: Variation is the enemy of quality.
>  
> Observation: When the health care of a single patient involves multiple health care individuals, organizations, record systems, venues, specializations, and the like patient safety is under challenge.
>  
> Observation: The causation of the St. Raphael Double Asphyxiation[1] <x-msg://67/#_ftn1> involved the interface between the patient respiratory equipment and the treatment room supply outlets.
>  
> Observation: The Challenger accident involved a defective physical interface, to wit: a field joint in the solid rocket booster[2] <x-msg://67/#_ftn2>.
>  
> Observation: An interface that does not exist cannot be involved in harm.
>  
> Observation: One of the most severe interface challenges is the organ transplant.
>  
> Observation: The Duke heart transplant tragedy involved defects in many interfaces, especially the interface between the organ supplying organization and the organ transplanting organization[3] <x-msg://67/#_ftn3>.
>  
> Observation: The causation of Davis-Besse 2002 near miss involved the mismanagement of the interface between the control rod drive nozzles and the control rod drives.
>  
> Observation: The triggering/initiating causation of the 1979 Three Mile Island Accident involved mismanagement of the unintended interface between the feedwater/condensate system and the instrument air system.
>  
> Observation: The causation of the Macondo Blowout and Explosion[4] <x-msg://67/#_ftn4> involved the interface between the installed well and the petroleum source.
>  
>  
> Observation: Investigations that include a swim lane diagram[5] <x-msg://67/#_ftn5> of event participants are more transparent on interfaces than those that do not.
> [6] <x-msg://67/#_ftn6> http://www.nytimes.com/2002/01/17/nyregion/hospital-says-two-died-in-nitrous-oxide-mistake.html <http://www.nytimes.com/2002/01/17/nyregion/hospital-says-two-died-in-nitrous-oxide-mistake.html>
> [7] <x-msg://67/#_ftn7> https://en.wikipedia.org/wiki/Space_Shuttle_Solid_Rocket_Booster <https://en.wikipedia.org/wiki/Space_Shuttle_Solid_Rocket_Booster>
> [8] <x-msg://67/#_ftn8> http://www.cbsnews.com/news/anatomy-of-a-mistake-16-03-2003/ <http://www.cbsnews.com/news/anatomy-of-a-mistake-16-03-2003/>
> [9] <x-msg://67/#_ftn9> http://www.csb.gov/macondo-blowout-and-explosion/ <http://www.csb.gov/macondo-blowout-and-explosion/>
> [10] <x-msg://67/#_ftn10> https://en.wikipedia.org/wiki/Swim_lane <https://en.wikipedia.org/wiki/Swim_lane>
>  
> Take care,
>  
> Bill Corcoran
> 
>  
> William  R. Corcoran, Ph.D., P.E.
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
> William.R.Corcoran at 1959.USNA.com <mailto:William.R.Corcoran at 1959.USNA.com>
>  <>http://www.linkedin.com/in/williamcorcoranphdpe <http://www.linkedin.com/in/williamcorcoranphdpe>
> https://www.box.com/shared/kfxg1lt9dh <https://www.box.com/shared/kfxg1lt9dh> 
> 
>  
> 
> From: "Grubenhoff, Joe" <Joe.Grubenhoff at CHILDRENSCOLORADO.ORG <mailto:Joe.Grubenhoff at CHILDRENSCOLORADO.ORG>>
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> 
> Sent: Friday, May 13, 2016 10:58 AM
> Subject: [Spam] Re: [IMPROVEDX] Hospital doctors... and other examples of care fractionation and commoditization
>  
> I think we can all agree that hand-offs lead to fractionation of health care and that they undeniably introduce opportunity for harm and missed opportunities for diagnosis. But I have trouble with the underlying resentment that physicians who do shift work (intensivists, hospitalists, EPs) don’t get to know their patients. Yes, we certainly don’t know our (or your) patients as well as their PCPs and don’t claim to. But to cast out that we don’t have the inclination to get to know them or try to is perhaps a little too far.
>  
> Those of us in these roles are responding to forces that, in many respects are beyond our control. EMTALA requires that I at least screen every patient that walks through my door. As a “safety-net” EDs are crushed with high volumes and undifferentiated illness acuity – time is a commodity that is finite. Capitation and declining reimbursements make it nearly impossible for a PCP to round on their admitted patients so the specialty of hospital medicine has sprung up. Advances in life-saving technologies necessitate that the specialty of critical care be facile with each new one that shows up.
>  
> I don’t know of anyone in any “shift-work” specialty claims to know a PCP’s patient better than the PCP does. But we all have a chance to improve the situation by picking up the phone to discuss the patients. I can do much better by a PCP’s patient if I get a phone call saying, “Hey, here’s the pertinent history/physiology/sociology of Mrs Z that I’m sending to the ED and what I am hoping for her visit.” The corollary to this is me calling back the PCP who sent the patient after I have completed my initial workup to say, “Here’s what I found. Am I missing something?” If we talk of “ownership of the patient” then don’t we each bear some responsibility to take the burden of checking in with the last provider to figure out where things stand?  
>  
>  
> Joe Grubenhoff, MD, MSCS| Assistant Professor of Pediatrics 
> Section of Emergency Medicine | University of Colorado
> Children's Hospital Colorado
> 13123 East 16th Avenue, Box 251  |  Anschutz Medical Campus  |  Aurora, CO 80045 | Phone: (303) 724-2581 | Fax: (720) 777-7317
> joe.grubenhoff at childrenscolorado.org <mailto:joe.grubenhoff at childrenscolorado.org>
> 
> Connect with Children's Hospital Colorado <http://www.childrenscolorado.org/> on Facebook <http://www.facebook.com/childrenshospitalcolorado> and Twitter <http://twitter.com/childrenscolo>
> 
> <image001.jpg>
> For a child’s sake…
>                 We are a caring community called to honor the sacred trust of our patients, families and each other through
>                 humble expertise, generous service and boundless creativity.
> …This is the moment.
>  
> From: DR WILLIAM CORCORAN [mailto:williamcorcoran at SBCGLOBAL.NET <mailto:williamcorcoran at SBCGLOBAL.NET>] 
> Sent: Friday, May 13, 2016 9:11 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Hospital doctors... and other examples of care fractionation and commoditization
>  
> The more "fractionation", the more hand-offs.
>  
> Every hand-off introduces an opportunity for harm.
>  
> The larger issue is interfaces in health care.
>  
> Take care,
>  
> Bill Corcoran
> 
>  
> William  R. Corcoran, Ph.D., P.E.
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
> William.R.Corcoran at 1959.USNA.com <mailto:William.R.Corcoran at 1959.USNA.com>
> http://www.linkedin.com/in/williamcorcoranphdpe <http://www.linkedin.com/in/williamcorcoranphdpe>
> https://www.box.com/shared/kfxg1lt9dh <https://www.box.com/shared/kfxg1lt9dh> 
>  
> From: "Bruno, Michael" <mbruno at HMC.PSU.EDU <mailto:mbruno at HMC.PSU.EDU>>
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> 
> Sent: Friday, May 13, 2016 6:58 AM
> Subject: Re: [IMPROVEDX] Hospital doctors... and other examples of care fractionation and commoditization
>  
> Hi Bob,
>  
> First of all, I'm extremely glad you're still with us and glad you were smart enough - and oppositional enough - to ignore bad advice when you received it!
>  
> I think you've put your finger on a very important issue here: the fractionation and commoditization of care due to our provider-centric divisions of labor in medicine to fit in neat little bins of roles and time slots has become a huge risk-factor for error in and of itself.  This is partly because of a shortage of physicians and a recognized premium on moving toward subspecialization, to be sure, and isn’t made better by giving our trainees ‘work-hours restrictions’ that promote the concept that medicine can be practiced conveniently, in comfortable shifts, etc.  But we have been going down a path where medical care is treated entirely as a commodity, where physicians are viewed as interchangeable cogs in a machine, differing only in their specialty/subspecialty.  The patient is not at the center of this model, clearly.  It’s a provider and institution-centric model that favors maximizing practice efficiency, controlling costs, and getting the most out of our manpower.
>  
> This problem was summed up nicely in the 19th century by Sr. Wm. Osler, who made a clear distinction between a doctor who treats a disease and one who treats a patient with a disease.  This implies (correctly, I think) that medical expertise includes knowing your patient, which takes time, unfolding as all relationships do, out of multiple encounters spaced out over months and years.  It is NOT enough to simply know the usual disease processes and what treatments are recommended and what the practice guidelines are and apply them to patients who you have known for only 15 minutes.  At least not 100% of the time.  Part of the knowledge base we use to help our patients is our knowledge of diseases and part of it is our knowledge of them.  And this is made impossible with a fractionated model, made up of physicians who work a shift and will never have the opportunity (even if they had the inclination, which they probably don't) to get to know you and the individual aspects of your case and your physiology/history/sociology, etc.  Could this not underlie our widespread epidemic of physician ‘burnout’?
>  
> Also, a related problem is that the EHR is a very bad method of doing 'handoffs.'  Just last night I was asked to interpret a STAT portable CXR on a critically ill patient and searched the medical record for information - ANY information - about him that would help me make sense of the mess that I was seeing inside of his lungs.  The patient had been transferred from another hospital six hours earlier.  And you know what I found?  Nothing!  There were no notes, no H&P, no lab results yet, no nursing assessments, nothing.  Only the report of a trans-esophageal echocardiogram that had been done at the time of transfer.  Nothing else.  So I did the best I could with the limited information I had.  How many times had that patient's care been passed between different doctors, and who - if anyone - took "ownership" of his case?
>  
> Happy Friday the 13th!
>  
> All the best,
>  
> <image002.png>
> Michael A. Bruno, M.D., F.A.C.R.
> Professor of Radiology & Medicine
> Vice Chair for Quality and Patient Safety
> Chief, Division of Emergency Radiology
> The Milton S. Hershey Medical Center
> Penn State College of Medicine
> 500 University Drive, Mail Code H-066
> Hershey, PA  17033
> 
> Phone: (717) 531-8703
> Fax:      (717) 531-5737
> 
> e-mail: mbruno at hmc.psu.edu <mailto:mbruno at hmc.psu.edu>
>  
>  
> <image003.png>
> 
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> -----Original Message-----
> From: Bob Gorman [mailto:bgorman at KNCELL.ORG <mailto:bgorman at KNCELL.ORG>] 
> Sent: Thursday, May 12, 2016 11:14 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: [IMPROVEDX] Hospital doctors...
>  
> With so many types of deadly errors, you probably don't want to hear about yet another one. But it kills patients, so here it is.
>  
> I'm 74 years young. I've never had a flu shot or the flu. Then I got the flu. I called my PCP who urged me to go to the local ER.
> Error point #1, control of my health passed from my PCP, whose known me for 28 years to the ER doctor who doesn't know me at all. He wasn't very optimistic, and gave me a 50%-50% of living till morning. Fortunately, I picked the right 50% so I'm here writing these words.
>  
> But a subtle Error #2 occurred, when I was admitted to the hospital - my health decisions will now be made by a 'hospital'
> doctor, who also doesn't know a thing about me. After 3-4 days he considered, correctly, that I was too weak to return home, I live by myself, and sent me to e physical rehabilitation facility. Now the fun begins. The re-hab doctor, #3, who also doesn't know me, puts me on a limited fluid diet, even tho the floor nurses say, emphatically, that I'm dehydrated.
>  
> Fortunately, I have a strong oppositional defiance strength, so I let them do all their arguing, smiled widely, then when they were all gone, I got up and went to the sink in my room and had a tall cup of cold water. When I left the re-hab facility, I was given a long list of Rx most of which I ignored.
>  
> I'm still alive to write these words, many others are not. I'm not sure what to call this thread, 'Hospital doctors', switch of control', 'systemic error' or whatever, I'll let you guys & gals fight over a title...
>  
> Bob
>  
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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