Still Looking For Positive EHR Effects

Our health system just underwent an upgrade from the 2009 version of an EHR to the 2012 version.  The color scheme is a little different.  The painfully cluttered workflow is not significantly changed.  I’m sure there are many Very Important Features – likely relating to burdensome documentation regulations – but, from a clinical standpoint, it still feels like we’re working with Windows 3.1.

But, we suffer this hacked together kludge because of the promise for tangible improvements in quality of care.  One area that has markedly changed with the advent of EHR is the ability to obtain significant medical histories on our patients – without the need to rely on the imperfect patient interview.  The hope of these authors was that, if they compared patients for whom they had complete records established in the EHR to patient who were EHR naive at their facility, they’d be able to demonstrate improvements in at leasts surrogate markers for patient-oriented outcomes.

Looking retrospectively at three EDs covering 13,227 patient visits, these authors found essentially statistical noise.  Comparing multiple outcomes including hospitalization, ED LOS, quantity lab orders, and hospital mortality, they found inconsistently distributed variation that is more likely attributed to unmeasured confounders than any element of the EHR itself.

Like most folks using EHRs, I suspect there are small, difficult-to-measure improvements in healthcare delivery.  Interoperability and centralized data sources would contribute vastly, I hope, to reduced testing and admission rates without adverse effects on outcomes.  However, we’re still waiting for proof.

“The impact of electronic health records on people with diabetes in three different emergency departments”
http://www.ncbi.nlm.nih.gov/pubmed/23842938

New South Wales Dislikes Cerner

The grass is clearly greener on the other side for these folks at Nepean Hospital in New South Wales, AUS.  This study details the before-and-after Emergency Department core measures as they transitioned from the EDIS system to Cerner’s FirstNet.  As they state in their introduction, “Despite limited literature indicating that FirstNet has decreased performance” and “reports of problems with Cerner programs overseas”, FirstNet was foisted upon them – so it’s clear they have an agenda with this publication.


And, a retrospective, observational study is the perfect vehicle for an agenda.  You pick the criteria you want to measure, the most favorable time period, and voilà!  These authors picked a six month pre-intervention period and a six-month post-intervention period.  Triage categories were similar for that six month period.  And then…they present data on a three-month subset.  Indeed, all their descriptive statistics are of only a three-month subset excepting ambulance offload waiting time – for which they have full six month data.  Why choose a study period fraught with missing data?

Then, yes, by every measure they are less efficient at seeing patients with the Cerner product.  The FirstNet system had been in place for six months by the time they report data – but, it’s still not unreasonable to suggest they’re somewhat suffering the growing pains of inexperience.  Then, they also understaff the ED by 3.2 resident shifts and 3.5 attending shifts per week.  An under-staffed ED for a relatively new implementation of a product with low physician acceptance?  

As little love I have for Cerner FirstNet, I’m not sure this study gives it a fair shot.


Effect of an electronic medical record information system on emergency department performance”
www.ncbi.nlm.nih.gov/pubmed/23451963

A Muddled Look at ED CPOE

Computerized Provider Order Entry – the defining transition in medicine over the last couple decades.  Love it or hate it, as UCSF’s CEO says, the best way to characterize the industry leader is that it succeeds “not because it’s so good, but because others are so bad.”  A fantastic sentiment for a trillion-dollar industry that has somehow become an unavoidable reality of medical practice.

But, it’s not all doom and gloom.  This systematic review of CPOE in use in the Emergency Department identified 22 articles evaluating different aspects of EDIS – and some were even helpful!  The main area of benefit – which has been demonstrated repeatedly in the informatics literature – was a reduction in medication prescribing errors, overdoses, and potential adverse drug events.  There was no consensus regarding changes in patient flow, length of stay, or time spent in direct patient care.  Then, on the flip side, some CPOE interventions were harmful – the effect of order set use as decision-support was implementation dependent, with some institutions seeing increased testing while others saw decreases.

A muddled look at a muddled landscape with, almost certainly, a muddled immediate future.  There are a lot of decisions being made in boardrooms and committees regarding the use of these systems, and not nearly enough evaluation of the unintended consequences.

“May you live in interesting times,” indeed.

“The Effect of Computerized Provider Order Entry Systems on Clinical Care and Work Processes in Emergency Departments: A Systematic Review of the Quantitative Literature”
www.ncbi.nlm.nih.gov/pubmed/23548404

“ePlacebo”-Controlled Trials?

This is a bit of a fascinating application of clinical informatics – using retrospective patient cohorts and propensity matching techniques to reduce the need for placebo groups in future trials.

This is work done by Pfizer on their own internal database, to address the ethical and financial concerns regarding recruiting large populations for new clinical trials.  For example, if you’re testing a new diabetes medication – do you really need a new control group, or can you sort of re-use the control group you had from the previous trial?  The answer of course, has traditionally been no – but their answer is yes-and-no.  Using their database of over 24,000 trials, they were able to identify 4,075 placebo-controlled groups, with varying degrees of data integrity, crossover, and parallel status.  They then suggest these groups could be used, when appropriate, as comparators in future studies in the same domain.

This is certainly an interesting application of clinical informatics – creating temporal databases of clinical trial patients with the potential to augment the evaluation of new medications.  What’s nice is that these authors appropriately recognize the limitations of such a database, noting it may only supplement, not replace placebo arms in future trials.

“Creation and implementation of a historical controls database from randomized clinical trials”
www.ncbi.nlm.nih.gov/pubmed/23449762

Informatics for Wrong-Patient Ordering

It seems intuitive – if, perhaps, the electronic health record has an updated problem list, and the EHR knows the typical indication of various medications, then the EHR would be able to perform some cursory checks for concordance.  If the orders and the problems are not concordant – then, as these authors propose, perhaps the orders are on the wrong patient?

This study is a retrospective analysis of the authors’ EHR, in which they had previously implemented alerts of this fashion in the interests of identifying problem lists that were not current.  However, after data mining their 127,320 alerts over a 6-year period, they noticed 32 orders in which the order was immediately cancelled on one patient and re-ordered on another.  They then conclude that their problem list alert also has the beneficial side-effect of catching wrong-patient orders.

A bit of a stretch – but, it’s an interesting application of surveillance intelligence.  The good news is, at least, that their problem list intervention is successful (pubmed) – because a 0.25 in 1000 patient alert yield for wrong-patient orders would be abysmal!

“Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE)”
www.ncbi.nlm.nih.gov/pubmed/23396543

Copy & Paste Medicine

Mostly unrelated to Emergency Medicine – but an interesting descriptive study of a downstream phenomenon I see on a frequent basis.  

For example, I’ll intermittently follow-up a patient to see how they fared as an inpatient.  I’ll read the inpatient documentation, consultant reports, etc. – and find the tiny EM HPI perpetuated throughout the chart with minimal modification.  This anecdotal experience is backed up by these authors who used text-compare software to identify copied passages in daily progress notes from an ICU setting.  In this ICU at MetroHealth in Cleveland, 82% of resident notes copied at least >20% of the text from the previous days’ progress note – and copied 55% of the prior content on average.  Attending notes were slightly less frequently copied (74%), but tended to copy more content (61%).

There’s no conclusive data regarding whether this copy/paste practice affects patient outcomes, but it’s an interesting symptom of evolving medical care and documentation in the EHR era.  I hope that, as HIT evolves, documentation tools trend towards encouraging concise, effective communication, rather than this sort of (likely ineffective) chart bloat.

“Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes”
www.ncbi.nlm.nih.gov/pubmed/23263617

The EHR – A Tool For Blocking Admissions

This is a mildly entertaining ethnographic study of how ED physicians, IM physicians, and surgeons used the Electronic Health Record (EHR) in the context of patient care in a tertiary medical center.

Essentially, the authors observed and interviewed residents and attendings in their use of the EHR, and identified its use in a function termed “chart biopsy” during the admission handoff process.  Inpatient teams were observed using the EHR to get a quick overview of the patient prior to the handoff, to provide the foundation for the history & physical, and – most entertainingly – to use as a weapon in negotiation and “blocking” potential admissions with ED physicians.  Other amusing anecdotes include the authors’ characterization of inpatient physicians feeling “less ‘at the mercy’ of ED physicians” after doing a pre-handoff chart biopsy, or feeling as though they could guard against the “disorganized ramblings” off the handoff process.

Overall, the authors correctly identify EHRs as increasingly prevalent supplements to traditional information gathering techniques, and make a reasonable proposal for evolution in EHRs to aid the “chart biopsy” process.

Chart biopsy: an emerging medical practice enabled by electronic health records and its impacts on emergency department-inpatient admission handoffs.”
http://www.ncbi.nlm.nih.gov/pubmed/22962194

Keeping Children Happy

When I started in medicine – hardly long ago – Child Life, if it existed at all in the Emergency Department, might have consisted of a few plastic toys and perhaps a Nintendo Entertainment System.  Now, the staple of every department is an iPad, filled with apps and distractions for children.

This is a short article from the Pediatric literature reviewing a few cases in which tablet computers proved useful, along with a review of several apps worth loading on for distraction during potentially troubling procedures.  Most of the apps reviewed are for iPad, but equivalent exist for Android devices and iPhone.



I’ve definitely gotten mileage out of the movie “Toy Story 3” on my iPhone – perfect for the 3 AM laceration repair when Child Life has gone home for the night.

“Using a Tablet Computer During Pediatric Procedures – 
A Case Series and Review of the ‘Apps'”

How Many Emergency Physicians Are On Twitter?

672.

Or, at least, that’s how many self-identified in their Twitter profiles as professional physicians in Emergency Medicine at the time this descriptive study was undertaken.  According to the author estimates, this accounts for ~1.6% of the ~20,000 U.S. board-certified Emergency Physicians.  The true number may be higher, owing to profiles that do not identify themselves professionally.

About half were “active” with a tweet within the last 15 days, and the other half were “inactive”.  Active accounts followed more users and were followed by more users.  They also have a visualization figure showing the interconnectedness of the active Twitter accounts, and, unsurprisingly, everyone tweets to the same group of twits, and vice versa.

So, it’s a small social media extension of the greater online presence of Emergency Physicians.  I’d probably say that the primary flaw with the service, regarding promoting wider interaction between online EPs, is that it is a closed, self-contained system separate from the other online resources visited by EPs.  The value is probably most to those who communicate and interact professionally in an active manner, whereas it doesn’t have as much to offer the passive observer.

“Analysis of emergency physicians’ Twitter accounts”
http://www.ncbi.nlm.nih.gov/pubmed/22634832

It Feels Good To Use an iPad

Recently, there has been a great deal of coverage on internet news sites with headlines such as “Study: iPads Increase Residency Efficency.”  These headlines are pulled from a “Research Letter” in Archives of Internal Medicine, reporting from the University of Chicago, regarding the distribution of iPads capable of running Epic via Citrix.

Sounds good, but it’s untrue.

What is true is that residents reported that they used the iPads for work.  The additionally thought that it saved them time, and thought it improved their efficiency on the wards.  This is to say, they liked using the iPad.

The part that isn’t true is where the authors claim an increase in “actual resident efficiency.”  By analyzing the hour of the day in which orders are placed, the authors attempt to extrapolate to a hypothetical reality in which this means iPads are helping their residents place orders more quickly on admitted patients, and to place additional orders while post-call, just before leaving the hospital.  There is, in fact, no specific data that using the iPad makes the residents more efficient, only data showing the hour of the day in which orders are placed has changed from one year to the next.  The iPad has, perhaps, changed their work habits – but without prospectively observing how these iPads are being used, it is impossible to conclude how or why.

But, at least they liked them!  And, considering how addictive Angry Birds is, I’m surprised their productivity isn’t decreased.

“Impact of Mobile Tablet Computers on Internal Medicine Resident Efficiency”

http://archinte.ama-assn.org/cgi/content/extract/172/5/436