[Spam] Re: [IMPROVEDX] The Dangers of Copy and Paste in the EHR

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Tue Oct 25 04:25:34 UTC 2016


This time with the Patient ToolKit, both in English and Spanish.
Peggy

Peggy Zuckerman
www.peggyRCC.com

On Mon, Oct 24, 2016 at 8:36 PM, Peggy Zuckerman <peggyzuckerman at gmail.com>
wrote:

> Love to share a patient committee "Patient ToolKit" which is intended to
> help prep a patient for a coming doctor appointment.  The goal was to give
> the patient a way to tell his story in a way more acceptable to the
> patient.  The secret sauce is the implicit message that this is the
> information that should be of interest to the doctor.  Hope to get some
> feedback on this,.
> Peggy
>
> Peggy Zuckerman
> www.peggyRCC.com
>
> On Mon, Oct 24, 2016 at 7:38 PM, Art Papier <apapier at visualdx.com> wrote:
>
>> Larry Weed MD has pointed out for greater than 40 years that the human
>> mind cannot recall all the questions to ask, nor remember all the diagnoses
>> and their variant presentations within the differential diagnosis.  Charles
>> Friedman PhD has reminded us that clinical decision support means computer
>> + brain > brain, and that computer assisted diagnosis is not a replacement
>> for sound clinical reasoning and judgment.
>>
>> Problem oriented computer assisted systems will generate not simple
>> “clipboard” checklists but problem oriented and individual patient context
>> specific historical questionnaires that can be answered by the patient at
>> home before the visit, in the waiting room and then jointly reviewed in the
>> clinic.  Building the “database” of relevant findings for clinical decision
>> making is key.  Why should this process be ad hoc, individually driven and
>> constrained by the limitations of human memory, limited clinician time and
>> a host of cognitive impediments?   Checklists are a great start as they
>> bring reliability, but computer algorithms and software will customize and
>> optimize the checklists to offer more precision.   There is so much
>> expertise that could be driven into a highly reliable, augmented history
>> taking process.  We are scratching the surface of how computing in
>> healthcare can bring relevant information to patient and physician.
>> Unfortunately we have burdened our clinicians with mind numbing clerical
>> tasks, rather than supported them with elegant cognitive support systems.
>>  We are hindered by the current reality of billing systems that are called
>> electronic health records, and legacy textbook publishing that are simply
>> books on line.  We should challenge ourselves to envision ideal information
>> systems, rather than to be constrained in our aspirations by the current
>> state of the EHR’s.   Improving physician performance is tied to
>> unburdening them from many of the impossible memory tasks, the grind of
>> data entry and supporting them with cognitive tools that guide and
>> suggest.
>>
>>
>>
>> *Art Papier MD*
>>
>> CEO
>>
>> *phone* 585-272-2630
>>
>> *mobile* 585-615-8245
>>
>> *address* 339 East Ave, Suite 410 Rochester, NY 14604
>>
>> *web* visualdx.com
>>
>> *email* apapier at visualdx.com
>>
>>
>>
>> [image: https://newoldstamp.com/editor/images/f.jpg]
>> <http://facebook.com/visualdx>  [image:
>> https://newoldstamp.com/editor/images/tw.jpg]
>> <http://www.twitter.com/visualdx>  [image:
>> https://newoldstamp.com/editor/images/in.jpg]
>> <http://linkedin.com/company/logical-images>  [image:
>> https://newoldstamp.com/editor/images/instagram.jpg]
>> <http://instagram.com/visualdximages>
>>
>> [image: cid:image005.png at 01D159E6.3E7218B0] <http://www.visualdx.com/>
>>
>>
>>
>>
>>
>> [image: cid:image006.jpg at 01D159E6.3E7218B0]
>>
>>
>>
>>
>>
>> *From:* Elias Peter [mailto:pheski69 at GMAIL.COM]
>> *Sent:* Monday, October 24, 2016 8:57 PM
>> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> *Subject:* Re: [IMPROVEDX] [Spam] Re: [IMPROVEDX] The Dangers of Copy
>> and Paste in the EHR
>>
>>
>>
>> I hate those questionnaires. I hate them when I have to fill them out for
>> myself or for family members,  and I hate them when I have to review them.
>> Sadly, they have become a fixture in medicine.  I have this fantasy that we
>> could have a system where a ‘facilitated history’ is developed during a
>> conversation between the patient (and family if the patient is willing) and
>> a trained clinical history taker. This would be comprehensive but relate to
>> past events, not the current issues, which really need an active
>> conversation with the clinical care team rather than a data collection
>> system. This facilitated history, once collected, should then be something
>> the patient has control of and can provide in part or full to members of
>> the care team. It would need to be editable in the sense of adding new
>> information or correcting errors, but would be relatively static.
>>
>>
>>
>> I cannot imagine holding a patient responsible for errors in the record
>> unless/until the patient is allowed to generated/maintain the record. Even
>> then, I have misgivings. I do not want to be held liable for errors in the
>> way I describe malfunctions in my furnace to the repairman. If I willfully
>> deceive the repairman (or my clinician) the repairman (or clinician) should
>> not be liable for acting on my deceptive information.
>>
>>
>>
>> Peter
>>
>>
>>
>>
>>
>> On 2016.10.24, at 6:46 PM, HM Epstein <hmepstein at GMAIL.COM> wrote:
>>
>>
>>
>> Dear Peter:
>>
>> I wish you were my physician. Any plans to move to NYC?
>>
>>
>>
>> When I referred to questions in my response to Rob, I meant the patient's
>> history as filled out on 10 pages of badly photocopied sheets on a
>> clipboard with too little space for any details  (in some offices replaced
>> by a clumsy computer tablet) and with a long list of questions the patient
>> has to answer. History of illness and surgeries, family history, current
>> medications, allergies - medicine and environmental and foods, and so on.
>> This is the data that *should* end up in the EHR along with the
>> examination notes, test results, etc.
>>
>>
>>
>> I was reacting to his suggestion that the patient or their designee (or
>> mommy) can be held liable for errors on that document. I think that's
>> untenable until filling out those forms becomes less onerous. I don't know
>> how many young moms juggling two kids or elderly patients struggling to
>> read the small broken type I've seen sigh and shake their heads and give
>> up.
>>
>>
>>
>> I had suggested to my Ob/Gyn that her patient history forms should
>> include a few missing questions. One example was to ask if the patient had
>> any new or recent GI symptoms, since those may be the only warning signs of
>> ovarian cancer that ever show. (A close friend is dying, stage 4, which was
>> discovered only because she was in so much pain, she thought it was her
>> appendix and went to the ED. However, she had seen her Gyn regularly and
>> had been experiencing relevant GI symptoms for a year. No one asked her, so
>> she never thought to mention it to her Gyn.)
>>
>>
>>
>> With most of my physicians, they will ask questions while examining me
>> and after. However, the patient shouldn't be liable for errors in that
>> situation either. Communication doesn't happen until one person understands
>> the other and then responds. Hopefully without one hand on the doorknob or
>> one's head in the laptop.
>>
>>
>>
>> Best,
>>
>> Helene
>>
>>
>> hmepstein.com
>>
>> @hmepstein <https://twitter.com/hmepstein>
>>
>> Mobile: 914-522-2116
>>
>>
>>
>> On Mon, Oct 24, 2016 at 4:47 PM, Elias Peter <pheski69 at gmail.com> wrote:
>>
>> I was trained to believe that questions come at the very end of the
>> process of learning the patient’s history. Any history developed primarily
>> by a Q & A process is tremendously at risk for being driven by the
>> clinician’s frame, not the patient’s frame. Once this has happened, it is
>> very hard to upright the bell. Here is what I was taught:
>>
>>
>>
>>    - One starts with an open-ended question, such as: “Let’s start by
>>    having you tell me what’s been going on and what your concerns are.”
>>    - Then the patient is allowed to tell his-story or her-story until
>>    they reach the end, with minimal prompting and preferably no interruptions.
>>    Good ‘prompts’ are ‘Mmm’ and ‘I see’ and ‘And then?’
>>    - Only when that process is done, is it time to ask questions:
>>    "Thanks. Now I need to ask come questions to clarify things or fill in some
>>    details. Let me know if you don’t understand the question or why I am
>>    asking.”
>>
>>
>>
>> The computer-centric EHR did not exist back then. Several years ago I
>> began encouraging patients to see what I am typing while I am typing, and
>> giving them a copy of the note at the end of the visit.
>>
>>
>>
>> Peter Elias
>>
>>
>>
>>
>>
>> On 2016.10.24, at 4:28 PM, HM Epstein <hmepstein at GMAIL.COM> wrote:
>>
>>
>>
>> Hi Rob:
>>
>> You asked if the patient or the patient's designee should be legally
>> responsible for their part of the history. IMO that's legally and morally
>> untenable because the patient is only going to answer the questions they've
>> been asked or share what they think is key.
>>
>>
>>
>> First, the questions have to be relevant. I just went in to see an
>> OB/GYN, for an annual check up. It was my first time visiting the practice.
>> I answered all of the questions to the best of my knowledge but when I met
>> the physician, I informed her that there were several questions she
>> should've asked and didn't. We had an interesting discussion and I ended up
>> getting a more thorough exam and series of tests than I might have. But I
>> am a patient and the parent of a patient who have both been multiply
>> misdiagnosed, and several times with severe consequences, so I've been
>> educated in the worst way possible. The majority of Americans have not been
>> through that same trial.
>>
>>
>>
>>  Additionally, you can't hold a patient responsible for an incomplete or
>> inaccurate history when the amount of time the patients get with their
>> physicians has been shrinking steadily to the medical equivalent of a
>> tweet. I'm not able to check my database but I recall hearing that the
>> average patient is given only 90 seconds to explain why they're
>> there before they're interrupted by the doctor and that a hospitalized
>> patient gets only eight minutes with the attending. So, how are they
>> supposed to tell the full story of a prolonged diagnostic journey? They may
>> not even know it's been a prolonged diagnostic journey because they've
>> accepted the partial or incorrect diagnosis they have been given before.
>>
>>
>>
>> Plus patients suffer all of the same cognitive errors that doctors are
>> prone to and they've made the incorrect data part of their medical history.
>> I don't know how many physicians I told that my son was suffering from
>> PANDAS -- which was incorrect but was what he was being treated for. I
>> prepared the ground for an anchoring bias thinking I was being helpful in
>> providing what I considered to be key information. I was wrong, of course.
>> But I was also tired of my son being misdiagnosed with growing pains and
>> allergies when he was profoundly ill and getting worse. I hear this again
>> and again and again from family is a pediatric patients I've interviewed.
>>
>>
>>
>> I would rather a patient say to the physician, "Here are my symptoms and
>> the reasons I'm coming in, here are my current medications and Rx
>> allergies, my birthdate, and that's all I can share with you. Figure the
>> rest of it out." I also would prefer every physician assume that the
>> medical history in front of them has inconsistencies and inaccuracies that
>> need to be investigated. I think we might end up with better results.
>> Perhaps with the reimbursement changes in Medicare and Medicaid, we're
>> getting closer to that happening.
>>
>>
>>
>> Best,
>>
>> Helene
>>
>>
>>
>> *-- *
>>
>> *hmepstein.com <http://hmepstein.com/> *
>>
>> *@hmepstein*
>>
>> *Mobile: 914-522-2116 <914-522-2116>*
>>
>>
>>
>> *Sent from my iPhone*
>>
>>
>>
>>
>>
>>
>> On Oct 23, 2016, at 1:38 PM, robert bell <0000000296e45ec4-dmarc-reques
>> t at LIST.IMPROVEDIAGNOSIS.ORG> wrote:
>>
>> Very good point William.
>>
>>
>>
>> Should the Physician, HCP, Consultant, Patient or Patient’s designee be
>> legally responsible for their part of the accuracy of the information in
>> the EMR?
>>
>>
>>
>> Would that help move towards greater accuracy?
>>
>>
>>
>> Rob
>>
>> On Oct 23, 2016, at 4:42 AM, DR WILLIAM CORCORAN <
>> williamcorcoran at sbcglobal.net> wrote:
>>
>>
>>
>> Minor Issue
>>
>>
>>
>> It is only after the harmful events that they are involved in can you
>> tell that errors, anomalies, deviations, changes, and differences were
>> minor.
>>
>>
>>
>> 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
>> http://www.linkedin.com/in/williamcorcoranphdpe
>>
>> https://www.box.com/shared/kfxg1lt9dh
>>
>>
>>
>> On Saturday, October 22, 2016 8:26 PM, robert bell <
>> 0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> wrote:
>>
>>
>>
>> How frequently does a patient’s history/story change?
>>
>>
>>
>> How frequently does a patient give the wrong history and relevant
>> information?
>>
>>
>>
>> it seems that some level of error must be accepted but it also seems that
>> we should attempt to reduce as much error as we can.
>>
>>
>>
>> And patient involvement should be encouraged to facilitate that.
>>
>>
>>
>> Rob Bell
>>
>>
>>
>>
>>
>> On Oct 22, 2016, at 11:29 AM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM>
>> wrote:
>>
>>
>>
>> Part of the issue which must be considered, whether in a cut and paste
>> situation, or in the retrieval and use of any record, is that there are
>> likely errors which could be corrected by the patient, and rarely is that
>> permitted.
>>
>>
>>
>> There is the issue beyond that in which those corrections, whether from
>> patient or physician, are not broad-reaching, such that another
>> doctor/institution using their version of the record does not those
>> corrections.  And there may be errors as to basic identity in up to 15% of
>> records.  The misidentified patient may be treated multiple times, with
>> those additions further affecting that record.  Naturally the 'real'
>> patient who then is properly identified with that record is now confused
>> with the misidentified patient.
>>
>>
>>
>> Peggy Zuckerman
>>
>>
>> Peggy Zuckerman
>> www.peggyRCC.com <http://www.peggyrcc.com/>
>>
>>
>>
>> On Sat, Oct 22, 2016 at 6:25 AM, Swerlick, Robert A <rswerli at emory.edu>
>> wrote:
>>
>> I believe the cut and past phenomena and the concerns raised miss an
>> important point. When a patient is seen over time, what information MUST be
>> carried forward in order to manage the patient? I certainly should not be
>> in a position where when I see a patient back I walk in the room totally
>> ignorant of their history and course other than what I remember from
>> recall.
>>
>>
>>
>> What information should ALWAYS be carried forward and where should this
>> reside within the record. Cut and paste is a convenient but flawed approach
>> to a real problem which does not have a tool within EHR's which allows for
>> ready access to information we should all have when we have a encounter and
>> are called upon to make clinical decisions.
>>
>>
>>
>> Before we condemn the cut and paste practice wholesale, we need to
>> consider what alternatives exist to replace the functions it fulfills.
>>
>>
>>
>> Robert A. Swerlick, MD
>>
>> Alicia Leizman Stonecipher Chair of Dermatology
>>
>> Professor and Chairman, Department of Dermatology
>>
>> Emory University School of Medicine
>>
>> 404-727-3669
>> ------------------------------
>>
>> *From:* HM Epstein <hmepstein at GMAIL.COM>
>> *Sent:* Saturday, October 22, 2016 1:16:14 AM
>> *To:* IMPROVEDX at LIST. IMPROVEDIAGNOSIS.ORG
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> *Subject:* [IMPROVEDX] The Dangers of Copy and Paste in the EHR
>>
>>
>>
>>  ​I was surprised by this report from ECRI. They did a retrospective
>> look at EHRs and found only 7.4% used cut-and-paste​. However, of that
>> small sample, 36% of the cut-and-paste entries contributed to Dx error.
>>
>>
>>
>> Based on all of the complaints I've read about cut-and-paste use in EHRs,
>> I truly expected to see that the incidence was much higher. Has anyone seen
>> other studies to compare to this? Does it accurately reflect your
>> expectations from your own observations in your place of work?
>>
>>
>>
>> Thank you.
>>
>>
>>
>> Best,
>>
>> Helene
>>
>>
>>
>> http://www.diagnosticimaging. com/ehr/dangers-copy-and- paste-ehr
>> <http://www.diagnosticimaging.com/ehr/dangers-copy-and-paste-ehr>
>>
>>
>> The Dangers of Copy and Paste in the EHR
>>
>> October 21, 2016
>>
>> *By Erica Sprey <http://www.diagnosticimaging.com/authors/erica-sprey>*
>>
>> By nature of design, EHR systems encourage physician users to copy old
>> patient data, like medication lists and chronic conditions, and copy and
>> paste the information into the current note. In doing so there are benefits
>> and risks for both physicians and patients, according to Lorraine Possanza,
>> DPM, JD, and Robert Giannini, NHA, of the nonprofit ECRI Institute
>> <https://www.ecri.org/Pages/default.aspx>. Possanza and Giannini were
>> co-presenters at the American Health Information Management Association's (
>> AHIMA <http://www.ahima.org/>) annual conference in Baltimore, Md., held
>> on Oct. 17, speaking on "Safe Practices for Copy and Paste."
>>
>> The ECRI Institute's mission is to provide physicians and other health
>> professionals evidence-based guidelines on the most effective medical
>> procedures, devices, and drugs, via scientific research. In order to
>> understand the affect that potentially unsafe practices like "copy and
>> paste" have on patient safety, ECRI applies a three-prong approach, says
>> Possanza. This includes data collection; data analytics; and leveraged
>> learning that reaches out to both EHR vendors and medical staff.
>>
>> While reporting can seem onerous to overworked staff, it is vital to
>> understand the extent of the problem. Possanza provided conference
>> attendees an example where copy and paste can hinder the physician and her
>> staff as she treats a hospitalized patient who suffers from pressure
>> ulcers. If the initial assessment is copied and pasted forward in the note
>> on subsequent patient visits, the physician does not have a true picture of
>> the progression of the ulcers and may not trust the validity of the
>> information in the note.
>>
>> Copy and paste also contributes to "note bloat" says Possanza, making it
>> difficult for a physician to pick out pertinent information that is
>> swallowed up by redundant information. It is vital that patient information
>> is accurate, timely, and easily assessable she says, adding that a dense
>> note can contribute to diagnostic error.
>>
>> The ECRI Institute did a retrospective study on diagnostic error that
>> found 7.4 percent of audited charts contained copy and paste information,
>> and of that group, 36 percent contributed to diagnostic error. "How does
>> copy and paste influence [diagnostic error]? Through note bloat, through
>> those internal inconsistencies, through the propagation of errors," says
>> Possanza. "If I pasted information and it's incorrect and I repeatedly
>> paste that information that is incorrect, I now have errors that are
>> propagated."
>>
>> In order to minimize the chances of error, Possanza says physicians and
>> other clinicians must be accurate in their notes, concisely document the
>> patient information, attribute where copy and paste material came from, and
>> give context where appropriate.
>>
>> It is essential that physicians and other medical staff feel that they
>> can report health information technology (HIT) related-errors in a
>> non-punitive environment, so that management can address any systemic
>> problems. And it is also equally important that staff are trained on copy
>> and paste best practices. To that end, the Partnership for HIT Patient
>> Safety <https://www.ecri.org/resource-center/Pages/HITPartnership.aspx> has
>> released the first "Health IT Safe Practices: Toolkit for the Safe Use
>> of Copy and Paste,"
>> <https://www.ecri.org/Resources/HIT/CP_Toolkit/Toolkit_CopyPaste_final.pdf> which
>> examines the scope of the problem, defines the various stakeholders and
>> provides safe-practice guidelines for providers.
>>
>> The Partnership has developed four recommendations for providers and
>> their staff, says Possanza:
>>
>> A: Provide a mechanism to make copy and paste material easily
>> identifiable;
>>
>> B: Ensure that the provenance (and chronology) of copy and paste material
>> is readily available;
>>
>> C: Ensure adequate staff training and education regarding the appropriate
>> and safe use of copy and paste; and
>>
>> D: Ensure that copy and paste practices are regularly monitored,
>> measured, and assessed.
>>
>>
>>
>>
>>
>>
>>
>>
>> ------------------------------
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>>
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE
>> D1=IMPROVEDX&A=1
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>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>
>>
>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE
>> D1=IMPROVEDX&A=1 or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST
>> .IMPROVEDIAGNOSIS.ORG
>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>
>






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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