Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Optimization vs. Diminishing Returns

Some time ago I wrote about the Minimum Effective Dose (MED), the concept in which we seek to optimize our results with the smallest amount of whatever it is that we are using to achieve that outcome. The quest to find the MED is one that crosses quite easily between my day job (medical) and my own quest for health (CrossFit). A quick mention of Eva T in Outside magazine and the program she uses with her clients made me think a bit more on the MED. The Everyday Math column in the WSJ provided an enhanced vocabulary for the journey.

Sometimes the MED really is a “something” you take. Here one thinks of medicine or food, for example. More often is the case that we are looking at a dose of time or effort. Or perhaps both. In this case we are seeking to optimize the effort as it relates to the outcome, to make the value of outcome divided by effort as large as possible. The rate limiting factor here is the Law of Diminishing Returns, of course: at some point additional effort produces such a small incremental increase in the outcome that it becomes not worth making. This applies to everything from WODs/week (or day) to decorating a birthday cake. At a certain point you just have to feel you’ve succeeded.

How, then, to know when you have reached this optimal level? Eugenia Cheng, the mathematician who wrote the WSJ piece, offers the concept of the “minimal acceptable standard”. Once she has reached this outcome the additional effects garnered from more effort have moved beyond the point where Diminishing Returns kicks in and she simply accepts the outcome. We would call these “minimal standards” goals, but the concept is essentially the same. We want an outcome; setting a target or a goal is step one in optimization.

Cheng then goes on to refine optimization with a discussion about boundaries. One is your goal, of course. In real life others also exist, things like a 24 hour day and a 7 day week and the need to make a living. The dose you choose, both qualitatively (what it is) and quantitatively (how much you get) is unavoidably affected by boundary conditions over which you have less control.In the end no outcome worth getting happens without effort. Health, friendship, or the unraveling of a gnarly math problem–you’re going to put effort in to get your results out.

Maximizing your outcome-to-effort ratio is just another way to say you are seeking your Minimum Effective Dose, in CrossFit and elsewhere.

Mental Health is Part of Health

Some time ago I wrote about creating a way to measure health. Real health. Health that encompasses every aspect of what it means to be alive and well. As a CrossFitter I definitely included Coach Glassman’s Disease -> Health -> Wellness continuum, and I also acknowledged the critical importance of his concept of “Fitness over Time”. As a classically trained physician/scientist there is clearly a place for more traditional metrics like blood pressure, serum lipids and the like, although they may, indeed, be an variable that is ultimately tied to fitness.

Where my thoughts on defining and measuring health seem to depart from most current trends is in the recognition that mental health–emotional wellbeing—is as much a part of being healthy as any other thing we might examine.

Think about it for just a moment. Most of what we would classify as mental illness has as many outward signs that we can see as diabetes and hypertension. Which is to say, none. Yet we—all of us, not just CrossFitters—see nothing but the good in treating diseases like diabetes openly and aggressively. There is no stigma attached to seeking care for your hypertension or your elevated LDL. To the contrary, if someone who loves you discovers you quit measuring your glucose before you bolus your insulin, they are for sure gonna get in your grill.

For whatever reason, mental illnesses are looked at quite differently. No one is asking the person with chronic depression whether she is taking her life-saving medication, for example. We might notice an insulin pump on a friend or family member, but then it’s quickly forgotten. Everyone seems to be very uncomfortable around the young man who has very obvious hand tremors from the life-saving medication he takes for his Bipolar disease. We all seem to be so much more understanding when we have to wait for a response from someone suffering from Parkinson’s Disease than from the young women who has the same symptoms as a side-effect from the medicine that quiets the dangerous thoughts in her head from Schizophrenia.

It’s not even necessary to look only at these kinds of severe mental illnesses when we are examining the importance of mental or emotional wellbeing as an integral part of being healthy. What good does it do to have a 5:00 mile, a 500 lb. deadlift, and a 1:59 “Fran” if it was self-loathing that drove you in the gym to get there? You may be quite accomplished, the envy of your peers, at the peak of whatever life mountain you wished to climb, and yet you cannot feel joy. How is it possible to be healthy without joy? I look at Usain Bolt and what I see is quite possibly the healthiest man alive. My friend Tim, the writer, tells me that Justin Gatlin has nearly everything that Bolt has—youth, fitness, wealth—but the combination of failure to knock off Bolt, and the public disapproval reigned on him as boos from the Rio stands has left him emotionally broken. It’s subtle, but if you look at his face in the blocks of the 100M Final it’s there.

Our complex and conflicted attitudes and feelings about mental illness are especially evident when the topic of suicide comes up. Just typing the word makes me uncomfortable. Even how we describe suicide is fraught with hidden meaning that reflects our discomfort: someone has “committed suicide”. Right? Someone committed an act that we simply cannot fathom, one that leaves the survivors completely without any understanding whatsoever. How could someone DO that? It’s as if every suicide is the same as the suicide of the crooked prison warden in The Shawshank Redemption when he looks out the window and sees his fate arrive in the front seat of a State Trooper’s car.

In reality most of the time it’s simply not like that at all. Nothing about it is simple at all.

The outer walls at the periphery of my world have been breeched by suicide twice in the last couple of weeks. One of them actually does feel a bit like that prison warden. Frankly, I am too conflicted, too aware of the external circumstances and not enough aware of the internal life of the deceased to offer much right now. The other one, however, just stopped me in my tracks when I heard. The loss was profound.It has also introduced to me a new vocabulary that I truly believe provides a starting line from which we can change how we think about not only suicide, but all of mental illness. A friendly acquaintance lost his wife when she was killed by suicide.

We don’t need to know all of the details of the story. Suffice it to say that in the face of a child’s illness she suffered quietly. Too quietly to be noticed. Perhaps she didn’t realize how badly she was suffering, or maybe she was like so many of us and couldn’t bring herself to see her illness for the life-threatening entity that it was. No one will ever know. What is clear, though, is that this was not anything about commitment. Kidney failure may be cause of death in a diabetic, but it is diabetes that kills him. There is no difference here. The cause of death was suicide. Her disease, her depression is what killed this young woman.

Each of us has a very few moments in our lifetimes that forever change us. On the second Tuesday of July in 2006, unbeknownst to me, one of those moments was transpiring in a lonely, dark corner. Joyfully, the moment was a beginning, not an ending. Regardless, once learning of the moment I was changed forever. Now I knew. You cannot see any marks from mental illness, no swollen appendage or insulin pump. But it is there all the same, and it must be acknowledged and accorded the same degree of care as any other disease that may take our loved ones from us. Mental illnesses are real, and they can be deadly. There ought not be any conflict or discomfort in treating them.

We may stop losing so many of our loved ones when start to see emotional wellbeing as part of being healthy.

When “Team Player” Means It’s All You

“It’s better to full-ass one something than to half-ass a bunch of things.” Anonymous

Soon enough I will be living another week of on-call coverage for one of the largest hospitals in Ohio. When asked recently by colleagues why I still do hospital coverage I had to admit that I really didn’t have an answer. I don’t really have to do it, and yet it doesn’t really seem like it feels right not to. There’s a kind of “pay it forward” debt to the giants who came before me that still lingers, I suppose. That debt’s been paid, with a bundle of interest, many times over, and it may be time to close the ledger.

Why now? Well, it has very little to do with the work itself because that hasn’t really changed all that too very much over the years. No, it’s more about the work that’s NOT being done by others, work that they own and are responsible for and don’t do, that will ultimately drive me away from this part of my day job. It’s really no different than any other job or workplace anywhere. The lazy and the shiftless, the incompetent and the entitled all see it as just fine to kick the can downstream to whomever they can get away with kicking it to.

I’ll bet you just had a dozen images of this from your own life flash by, right?

Boy, there are a thousand reasons you will hear to explain and rationalize why they feel it’s perfectly reasonable to get you to do their work. After awhile it gets really old. The first thing you should do when you encounter this is to look within and make sure that YOU aren’t doing this anywhere to anyone else. Gotta make sure that your virtue is intact before you saddle up the high horse! Once you’ve ascertained that all is right and proper with your own work ethic you then have a bit of a choice to make: rock the boat or sail along. Sadly, though you know the consequences of the latter (you continue to do that slacker’s work), be prepared for the possibility of not being thanked for pointing out reality to bosses and co-workers. It’s entirely possible that you will be the one criticized. Totally fair, right?

In the end there is no best answer to this dilemma. All you can do is use the feelings generated in you by being on the receiving end of this work-shifting to make yourself a better worker, no matter who it is you do that work for. If you do, indeed, reach that point where you just can’t look at yourself in the mirror any more because the injustice is simply too much to accept, it’s OK to call it as you see it. That’s where I am today, and that’s what I’ll be doing while on call. To be sure, all of that “pay it forward” I’ve done will get me an audience, though it may not mean I will be able to effect change. Other than workload, that is. In this tiny part of my day job, I will continue doing the very best job I possibly can, as I always do, for each of my patients each time I see them.

What I won’t be doing is picking up the other half an ass that someone else missed before I full-ass my part of the job.

Brief Thoughts While Abroad (from Sunday musings…)

Man, if you read pretty much any news item from any viewpoint it certainly sounds like the world is heading to hell in a hand basket. War, terrorism, and murder abound making the world less safe than 10 or 20 or 100 years ago. Life expectancy went down in the U.S.; diseases must be winning the war. We are destroying the planet with the effluent of human existence, and the scourges of poverty oppress and suppress more people to a greater degree as wealth disparity increases worldwide.

It’s enough to make you bag your WOD and belly up to Pizza Hut delivers.

Only none of it is true. Well, except for the increase in wealth disparity that is. Even here it’s important to note that across the world extreme poverty is roughly 25% of what it was just 30 years ago, and real famine now affects less than 1% of the world’s population. 55% of countries now allow their citizens to vote, up from 1% in the 1800′s. 85% of the world’s citizens can read and write. Death from war is 1/4 of what it was in 1980, 1/6 of what is what in 1970, and 1/16 of what it was in the 1950′s.

How about here at home? The homicide rate is down to 5.3/100,000 from 8.5 over the last 3 decades. We are 95% less likely to die on the job, 96% less likely to die in a car crash, and 99% less likely to die in a plane crash over the past century. We work 22 fewer hours per week than 1900, and lose 43 fewer hours to housework. All but the smallest minority of the poor are housed with heat and air conditioning, are not malnourished, and have access to modern “necessities” like the internet.

What about the environment? Aren’t we dooming our planet because of our ever-increasing insults to the land, water, and land? 30 years ago we in the U.S. delivered 20 million tons of sulfur dioxide and 34.5 million tons of particulate matter pollution into the air. Those numbers are now 4 million and 20.6 million despite more people, more production and more miles driven. In 1988 there were 46 major oil spills; in 2016 there were only 5.

My point is simple: the world is NOT getting worse. It is NOT worse than it was in 1990 or 1970 or 1950, it is better. In no way do I wish for you to think that I am telling you that we should be satisfied with this, only that we ought not be working to continue to improve our world from a Henny Penny, the world is falling point of view. Reasonable people can disagree on the effects of disproportionate distribution of wealth on a forward going basis, but any objective evaluation of the progress of the human condition across the globe over the last 30 years must certainly reach the conclusion that the world is better off today.

I have found over the course of my brief moment on this rock that I am simply better at my own tiny contribution to making a tiny slice of the rock better if I am coming from a place of optimism rather than one of despair. Your mileage may vary, and I certainly do not mean to dismiss the negative effects of very personal trauma and challenge. For me what I see is momentum, and a challenge to maintain this very positive momentum.

Offloading info/Work

Why do I write? Why do I sit down and use time that could otherwise be put to use in the gym, or in the office, or even just hanging with the Man Cub? As a long-standing lover of language I am always on the lookout for the best vocabulary to explain concepts I sometimes struggle with. Offloading is a term that is used in this case to describe what it is that humans do with information that they do not need to keep on hand in “useful memory” space.

This is what I do with ideas when my “wetware” memory is full.

This is hardly new. Indeed, the sturm und drang associated with the mega-trends in education, etc. associated with our massive information/recall apparatus that is the internet actually has its origin in the Greek era of Socrates and the transition from an oral tradition to one in which teachings were written. (HT to Frank Wilczek). Prominent adherents to the oral tradition such as Socrates and Simonides argued forcefully that the advent of the written transfer of information would weaken the mind and produce an inferior type of intelligence. In a fascinating and delicious ironic twist, all we know of either of these men we know because someone else wrote down what they recalled hearing.

In my day job we are still encased in a paradigm in which information is transferred from teacher to student and then tested to see if that information has been committed to memory. Imagine, with the explosion of data now available in the world of medicine we test (and test, and test…) both new doctors and established ones to see if they remember a certain percentage of facts, regardless of how often those facts come into play in the act of practicing medicine. The CrossFit analogy is to test a trainer on the precise moment that the obturator engages in the deadlift. One neither needs to know this to teach the deadlift, nor does one need to have memorized this in order to have it on hand in the gym. So, too, in medicine.

Please don’t get me wrong, I still enjoy knowing a bunch of stuff and being able to call up that stuff without needing to use my Google-Fu. The reality is that we have made a move from memory in written form to memory in digital form that is just as profound and disruptive as that from oral to written. We have only to remember where it is we have stored our memories, our books and our music and our musings.

And our passwords. We still need to remember our passwords.

Equality and a Just Society

“Life’s not fair.” –Scar

What does equality mean? What does it mean to be equal? This came up this week in my day job. A study was done that proports to show that male and female eye doctors are paid unequally. The conclusions are false at the outset in this particular case because by law, services in this particular arena are paid exactly the same no matter who performs them, when or where. Unfortunately, the sensational lede taps into all kinds of notions of fairness, and all kinds of perceptions about what people assume must be true, that women make less than men for equal work. There is no question that this is the case is some walks of life, but interestingly the data (some of which the authors ignore in their quest to prove their preconception) proves otherwise in medicine. An opportunity to examine real differences in how men and women practice medicine is thus lost in the pursuit of an examination of the spiritual quest to combat inequality, even where none exists.

Is this the unicorn of equality? Is payment under government programs the only place where equality actually exists? Heck if I know. What interests me is the fact that the first assumption is that inequality is present. Inequality is the default setting. That there is an inherent degree of unfairness in pretty much any and every setting. Know what I think? Equality doesn’t exist. It cannot exist if we are to have an ever-improving world. There is nothing unfair about that in the least.

A just civilization establishes a floor below which allowing people to live is ethically wrong. For example, in healthcare it is my contention that we have a moral obligation to see that every citizen has access to care when they are sick. Inherent in this contention is that there is a basic level of care that meets this moral obligation by ensuring the same outcome as any other level of care. One could apply this same concept to food, clothing, and housing without missing a beat. We can think of the rights enshrined in the U.S. Declaration of Independence as a proxy for this baseline if you’d like. Life, liberty, and the pursuit of happiness make a very fine baseline.

One’s right to “life” necessarily includes a right to be fed, would you agree? Equality would mean that if one among us dines on Beef Wellington, than each among us must do so as well. This is where unthinking and unquestioning fidelity to “equality” brings you. In so doing it forces everyone to expend energy protesting “inequality” better put toward fulfilling the moral obligation to see that no one goes without protein. In healthcare we see all kinds of protests againts the inequality of care demonstrated by the horror of a VIP of some sort or another recuperating from a procedure in a luxury suite, while the proletariat must recover in the equivalent of a Hotel 6. The reality is that the outcomes will be equal; the moral obligation has been fulfilled. Above a basic level in pretty much any domain you wish to examine, equality does not exist. Sorry. Scar is right. Life’s not fair.

Is he really though? Saying that it’s not fair is the same as saying that inequality above that level at which everyone has a right to live is wrong. Here is where I part company with those who hew to this viewpoint. What does it matter that someone drives a Cadillac while another drives a Kia? Do both not get you to work on time? Or that Beef Wellington again: do you not get the same amount of protein from a hamburger? The example I am using in another conversation about equality in healthcare is similar: if a medicine is effective taken 4 times a day, is the fact that someone can pay more for a version that must only be taken once a day a measurement of unfair inequality? I vote “no”.

My strong feeling is that energy spent in some way protesting “equality” is energy that is not expended on the much more important task of fulfilling the moral obligation of raising everyone to that acceptable basic level. In may, in fact, work against that effort. That constitutes unfairness in my opinion. Advocacy and protest should be directed there, toward making sure that everyone has that most basic obligation covered. Once universal entry is accomplished across all applicable domains, the next task is to continually raise that basic level for everyone, no matter how far the gulf may be between that level and whatever the “sky’s the limit” level might be. One need only look at “poverty” or “hunger” and how the bar has moved ever upward there to see how this might work.

We have a moral obligation to see that true rights are available to all. It is unfair to those who have not yet achieved that most basic level when efforts to help them are diverted to the pursuit of an unachievable conceptual goal that neither feeds nor clothes nor cures those in need: equality.

Sunday musings 2/4/18

Sunday musings…Planes, trains and automobiles. Stuck in airports and on tarmacs without real internet connections…

Each year around this time Mrs. bingo and I travel to Mexico, ostensibly for work. Actually, I really do work while I’m here, although it’s easy to pretend I’m just on vacation when it’s 80 degrees and blue sky sunny. Especially with snow in the forecast in The Land. Funny trip in many ways this year, maybe our 5th going to the same hotel. Some of the staff clearly have at least a fuzzy memory of our last visit (Mrs. bingo is nice to everyone!), and although we were in the lap of luxury there was a slightly heightened sense of the country’s culture which seemed to be more evident for some reason.

“When in Rome…”  is an apt sentiment. Cultural sensitivity, being aware of where you are and those things that are just enough different there that you make an effort to avoid inadvertent offense, has gotten easier for me as I’ve gotten older. Wonder why that is? Anyway, I find myself on alert for little ways that I can demonstrate that I’m paying attention. For example, in Mexico your greeting changes with the time of day. “Hi, how are you?” fairly screams “American”, you know?

There are plenty of other examples of course, but the sentiment remains the same: open awareness that it is you who is the outsider, you who are the guest, should bring with it an effort at accommodating the customs of your hosts rather than the other way around. While I happen to be out of the country this is the case if you happen to be visiting a part of your home country that is starkly different from your home town. It’s a very simple kindness, too easy to offer to let the chance go by.

You know…like packing my red, white and blue #12 jersey during my layover in Philly.

I’ll see you next week…

–bingo

Sunday musings 1/28/18

Sunday musings…

1) Sun. The big yellow one is the sun. Cameo appearance in Cleveburg today.

2) Gentrification. Once applied only to neighborhoods that are taken over by younger, wealthier newcomers than present occupants, gentrify is now applied as a qualifier to anything that is “up-scaled”. Actually, anything that is so much as discovered and enjoyed.

Think collard green smoothies or beef-cheek pirogies.

3) Advice. “Never take advice from someone you wouldn’t want to change places with.” -Kelly Clarkson

Wow. Whether or not that is Ms. Clarkson’s own advice, or if she is passing on the best advice she’s ever received, that’s a pretty power-packed little morsel, would’t you say? I would amend it just a tad because for anyone who is content in life it is unlikely that there is anyone with whom you would do the total switch. How about “only take advice from someone who obviously took their own advice and saw stuff work out.”

4) Meaning. “Pursue what is meaningful, not [only] what is expedient.” -Jordan Peterson

How’s that for heavy advice? What Mr. Peterson is saying, I think, is that one should strive in at least some small part of one’s life to achieve an outcome that is even slightly more impactful than acquiring one’s next meal. Admittedly there is a part of the world for whom there is literally nothing more meaningful than that because doing so might take each waking hour to achieve, but face it, the simple fact that you are reading my drivel is evidence that you have covered the shelter, water, food thing.

So what’ll it be?

I really do think that the search for something meaningful need not involve something that will affect all of human life, though it certainly could. Bill Gates is interviewed in today’s NYT, and Mr. Gates not only has decided to pursue some pretty big, pretty meaningful things, he certainly has the wherewithal to succeed where you and I likely don’t even have the imagination to dream. Still, meaning in actions is there for the taking in endeavors of all sizes. What Mr. Peterson is suggesting is that one be more mindful as we choose at least some of our pursuits.

Today there will be minutes that are up for grabs, as this week there will be hours in play, and this year time for at least one bigger pursuit. This kind of exercise has been part of my make up for some years now, but Mr. Peterson’s elegant phrasing is worth noting for both internal and external consumption. You don’t have to start with something as grand as solving the world’s malaria problem a la Mr. Gates. Practicing, seeking to make more of the tiny actions meaningful, leads quite naturally in my experience to engaging in larger meaningful pursuits. Start small and work your way up.

Start today. Instead of Instagram or Facebook or Twitter tonight, pick up a child and read a little “Goodnight Moon” before bedtime.

I’ll see you next week…

–bingo

Adventures in EMR Vol 2 Postscript: Who Owns This Debacle?

The late, great Larry Weed, M.D., Professor of Medicine at the University of Vermont predicted both the age of EMR as well as the advent of IBM’s Watson, “Big Data”, and machine-learning in the practice of medicine. With the problem-oriented medical record in the form  of the SOAP note (Subjective -> Objective -> Assessment -> Plan) he codified a universal approach to essentially any medical problem evaluated in any patient. What was then called the Medical Center of Vermont implemented a data warehouse which allowed instant viewing of test data by computer throughout the institution ion the early 1980′s (the first “EMR” if you will), and sister institution the Maine Medical Center solved the problem of the handwritten order by adding computer order entry (CPOE) in 1984 or so. Despite all of the hoopla surrounding the Accountable Care Act’s carrot and stick drive to digitize the medical record, the horse was already out of the barn and slowly walking in that direction in the 1980′s.

Why, then, is the EMR landscape such a mess in 2018?

Our American healthcare landscape is blessed with a number of very large, prestigious institutions. They are self-professed and incessantly self-promoted as leaders in both thought and action when it comes to the advancement of medical care in all ways in the United States. It is right here in the laps of the leaders of those famed institutions that blame rests for the debacle that is the modern EMR. As early as 1990 and as recently as 2008 the opportunity to lead presented itself to our most august institutions. When given this opportunity to develop a new, better type of medical record that would aid in every aspect of caring for patients, our most important medical institutions punted.

When you think of the best medical care in the country, who do you think of? Pretty easy to answer that, I bet. The Cleveland Clinic, The Mayo Clinic, Yale, Stanford, the hospitals that made up what has become Harvard Pilgrim Health like Mass General, Brigham and Women’s and Beth Israel, Johns Hopkins, Baylor. Household names, all. Every single one of these institutions seeks to portray itself as the ultimate example of excellence in medical care, devoted above all else to the development and provision of care better than any and all competitors. Not only that, each wishes to project the most pious of images, one that espouses their monk-like devotion to doing what is best for their patients before all other considerations. With a building consensus that record keeping the old pen and papyrus way was hindering both present and future care, and indeed might be contributing to harmful care, the era was ripe for any or all of these presumably noble, altruistic non-profit institutions to answer the call.

When American healthcare was ready to look to any of these institutions to lead us into the digital information age, each and every one of them abdicated. The leaders of these and other great institutions had the chance to develop a true medical record in digital form that was first and foremost a tool to be used to improve the care that was provided in their institutions. They had the resources. Any one of them could have taken a leadership role in its development, not unlike the kind of leadership many of them have taken as the first institution in on cutting edge medical care such as organ transplantation or new generation cancer care.

Instead, both early and late, the leaders of each one of these major institutions chose a path with an eye not toward how the EMR would engage in the care of a patient, but in how it would engage with accounts receivable. Each institution opted to prioritize the growth of revenue over improved care. Everything is about maximizing the income of the institution, while at the same time minimizing the risk associated with billing.

J’accuse.

Think about that second part for a moment. EMR’s are not designed to promote the safety of an individual patient as she goes through her care experience (despite what the marketing brochures may tell you); for safety they are designed to limit the likelihood that a payer audit will find a lack of documentation that supports the charges. The bigger the company making the program, the greater is this emphasis. In the early 00′s any one of the above institutions (and Texas, and Ohio State, and Dartmouth, and…) could have launched a program that met all of the MEDICAL criteria for a good record. If they wanted to make a profit they could have sold the rights to use it.

Why don’t EMR’s communicate with one another? Were you aware that even institutions that run software from the same vendor do not have the ability to simply put notes from one another into a universal chart? Crazy, huh? Frankly I’m not really all that sure who is to blame for that particular bit of nonsense, but the obvious answer as to why your Epic chart can’t communicate with, say, Nextgen lies with that abdication of responsibility I spoke of above.

By not taking control of the process of EMR development at the outset all of our major medical institutions learned that 1) they never really bought an EMR, they just rent it which means that 2) they no longer really own their own information. What better way to remain in control if you are Epic than to prevent The Cleveland Clinic from banding together with The University of Pennsylvania as a bargaining unit than to prevent them from sharing patient information ON THE SAME DAMN PLATFORM?

J’accuse.

To their collective shame our most prestigious medical institutions and their leaders sold their souls by prioritizing their role as commercial entities rather than as leaders in medical care on behalf of patients. In the process they allowed themselves to be enslaved by the commercial interests that now control the medical record. Worse than that they created an additional barrier between a patient and his own medical record.

There has to be a bright spot, right? Some shining beacon, a last bastion, someone willing to stand against toute le monde and defend the honor of academia, to not become the next rhinoceros?  Certainly some institution was willing to stand up and do the right thing by saying “screw it”, we’re gonna make a killer EMR that does everything that Larry Weed said it should do first, and then figure out the billing crap later, right? Perhaps the medium sized Intermountain Health in Utah is on the right track, but all of the really big institutions turned belly up to submit to the demands of payers, hoping for a treat and a  belly rub. Surely UVM, the home of Larry Weed didn’t cave, right? The University of Vermont must surely have been driven by its early entry into the world of digital information management and created its own EMR that both houses information in a clinically relevant way, as well as allowing for computer-guided decision making, right? RIGHT?

Nope. Sorry. The University of Vermont runs on Epic.

 

 

Adventures in EMR Vol 2 Epilogue: May We Please Have…?

“The essence of Medicine is story—finding the right story….Healthcare, on the other hand, deconstructs story into thousands of tiny pieces…for which no one is responsible.” –Victoria Sweet, M.D.

Being forced out of your comfort zone in any endeavor is always painful. In my experience it is also conducive to learning something new, and at least in my case it is a catalyst for creative thought. What, then, have I learned from our forced-march, point-of-a-bayonet transition from one EMR system to a new one? Are there any lessons to be learned on a broader scale, beyond the walls of SkyVision? Can I take this bowl of lemons and create lemonade that can be passed around the much larger table that encompasses the broad landscape of American medicine?

First off, our collective experience with our transition reinforced my long-held contention that you simply can’t effect change in a system of any type without either being a functional unit in that system, or shadowing those who work in the system you wish to improve. Imagine designing the cockpit of the next generation fighter jet without ever actually either flying one or sitting next to someone while they fly it. Take a look back at my essay “EMR and Underpants”; our information ecosystem was designed by engineers far, far away from the point of care delivery. It’s roughly the same as giving someone the job of choosing what underpants to deliver for your daily wear without ever having seen what you look like or talking with you about how you wear your clothes.

After all of our struggles there does appear to be one, huge 30,000 foot lesson in all of this that should, by rights, become the foundation of the next wave of innovation in EMRs: the spoken word is the goal. What made our traditional scribe process so successful in both efficiency and accuracy was the development of charting based on a spoken narrative. The doctor would dictate exam findings. The scribe would then intuit the various diagnoses from the conversation occurring between the doctor and the patient. While the doctor then went on to outline the plan of action this, too, was transcribed into the medical record. It was a natural and familiar way for all of the players in the room to communicate.

Why can’t I do that with any of the EMRs available on the market? Why is it that I can’t talk to an EMR and have my verbal encounter become what we would all recognize as a progress note? Heck, I’d be thrilled if there was an interim step in which all of the BS clicking we are doing to check all of those boxes could turn into something that looked more like spoken English (although our new EMR is OK and getting a bit better on this). With all of the hundreds of millions of dollars being raked in by EMR behemoths like Epic you mean to tell me they can’t find the resources to make this happen? Please.

You see, the essence of every healthcare interaction is the spoken word. When you have to stop talking or listening you have devalued time. Think for a minute from the patient’s point of view: it doesn’t matter whether it is a doctor of some other kind of worker in the room, once attention is shifted from the patient to the screen quality plummets. Make me a poor man’s AI interface that I can cue verbally to let it know what I’m doing and put it in the right box so that Uncle Sam won’t ding me for being a poor data entry clerk. I’d even be willing to talk to Mrs. Pistolacklioni about her smoking at every 3 month follow-up for her severe glaucoma (a disease that has no increased risk if you smoked, by the way).

While I’m at it, and as long as we are talking about communicating (cue Paul Newman in Cool Hand Luke), may we please find a way for the real medical record to be freely available on every platform? Seriously, how did this one escape the cloistered engineers and double-blinded underwear salespeople? Your Samsung cell phone can call your buddies iPhone and vice versa. An airman flying a MIG 22 can communicate with an inverted Tom Cruise in a 3g dive because there is a single standard for radio transmission and reception. Come on. This is basic stuff, the equivalent of declaring the gage of railroad tracks. You mean to tell me that the same people who think they know so much about how things must be that they have an opinion on the shape of operating room hats somehow missed this? Again. please.

I’m not kidding about the OR hats by the way; some DA administrators simply declared that bouffant hats were safer because they think so and won’t come off that even in the face of randomized control studies to the contrary.

Seriously, go all the way back to Dr. Larry Weed at UVM in the 1980′s and return to his beloved premises. There is too much information to be contained in any one doctor’s head, and doctors cannot avoid their biases and frame of reference when making medical decisions. Having true interoperability across all platforms would allow the free movement of information at the direction of the patient, the person who should be in control of that information after all. (Note: Carbon Health is on to something)

As a society we’ve allowed ourselves to remain captives of the trial bar’s defense of the status quo when it comes to malpractice lawsuits. This, in turn, has prevented us from examining repeating errors to determine if there might be a common thread that could be altered and thereby reduce their frequency. Interoperability would allow just the sort of root cause analysis that is needed, and because it would be done using anonymous information no actionable disclosure would be necessary from the doctors involved. As a bonus this would probably allow us to create true, vetted care protocols for the majority of patients with the majority of problems, and this evidence based care would then have to be admissible in court. All that would be necessary would be for doctors to explain in their chart why they decided to deviate in an individual case if that came up. Bingo, a data-driven solution to defensive medicine, all from better communication.

My new vendor is unaware that I am writing this, but interestingly has invited me to consider joining their advisory board and to speak at their annual convention. Who knows if those invitations will continue to be extended once they read this, but if they are I will have two very simple, very basic messages. This whole medical record thing should be about communication, just like it’s always been from the days of Hippocrates. That, and that Larry Weed was right. Before we go any further forward go back and read Larry Weed.

All we need is a little electronic SOAP to clean up this mess.