Vol. 28 September 1, 2010 Computer Error or Patient-Centered Care?

September 1, 2010

The saga continues, but morphs from a discussion of computer error into patient-centered care (1).

In my last two posts I tell my story of trying to speed up a six-hour infusion of intravenous medication by correcting a “computer error”; a “failure to update reference information” in the computer available to the nurses. My first clue was the discrepancy between the medication’s package insert and the computer information. Discussion with the infusion nurses and a call to the Hospital’s chief pharmacist caused a review of the computer info, the package insert, and the hospital’s Pharmacy and Therapeutics Committee minutes.

The package insert stated that “after the initial 30 minutes without a side-effect the infusion rate could be gradually increased to the maximum rate.” The infusion nurses’ interpretation of “gradually” was a infusion rate step-up every 30 minutes resulting in a six-hour infusion. My preference was for a two hour infusion. I looked diligently, and in vain, for the manufacturer’s definition of “gradually”, so I called its 800 number . A very knowledgeable and accommodating RN in the Professional Services Department ( I identified myself as a physician) explained that they did not define “gradually”  because they wished “not to be too proscribing, realized that individual patients varied, and respected each facility’s responsibility to set their own protocols.” It sounded like pretty good risk management (avoidance of increased liability) to me.  She went on to say that many facilities had used a rate step-up schedule of 15 minutes rather than 30 minutes without increased side-effects and offered to send us the articles describing this.

Going to a step-up rate 0f every 15 minutes rather than 30 minutes would result in a four and a half hour infusion instead of a six hour one; still longer than my initially hoped-for two hours. Could the change in duration be labeled a triumph of “patient-centered care”? If so, was it worth all the time and effort?

As a physician, I am more informed than the average patient. As the retired Medical Director of the hospital where I was receiving the treatment, I knew and had good working relationships with my nurses and the pharmacist. As a physician seeking clarification about administration of their drug, I was accommodated and happily helped by the drug manufacturer. This process involved several discussions, local and long distance phone calls, sending of faxes, reviewing of minutes, and patience on the part of both providers and patient over several days; all for a rate of 4 1/2 rather than 6 hours for a just single medication. Was this negotiation worth it?

Don Berwick “uses his own wits to safeguard against errors” and now urges the adoption of patient-centered care to restore his dignity as a patient in the current medical world where “provider trumps patient” almost every time. (2) Negotiation between patient and provider from EQUAL bases seems to be the essence of patient-centered care.  The line between requesting and demanding can be a thin one. We successfully avoided defensive stances and threatening attitudes and never felt that we were engaged in a “dispruptive shift in control and power.” (3) Is it reasonable to expect the average patient and the busy provider to conduct such successful negotiations most of the time? That is a tall order, but I hope that healthcare systems will be able to  support the process without bogging down the providers and frustrating the patients.

1.  “Patient centered care means meeting patient’s needs and preferences through shared informed decision-making which will reduce unneeded and unwanted services” – See Institute of Medicine, Institute for Healthcare Improvement, Robert Wood Johnson Foundation, The Commonwealth Fund, The Joint Commission, and Patient-Centered Outcomes Research Institute websites and publications.

2.  Remarks by Don Berwick before the plenary session of  the International Forum on Quality and Safety in Health Care, Berlin 2009    http://www.youtube.com/watch?v=SSauhroFTpk

3. “What ‘patient centered care’ should mean: Confessions of an extremist.” Don Berwick, Health Affairs 2009 Jul-Aug 28 (4)

Vol. 27 August 15, 2010 No One Is Perfect, Not Even Computers.

August 10, 2010

My last post described how a precisely regimented dosage of intravenous medication delivered to me over six hours by a state-of-the art computer actually depended on the existence (and the survival for 6 hours) of a handwritten yellow Stickie hanging on my IV pole. I write this post as a recipient, certainly not a victim, since no harm occurred, of a “care error” caused by a computer.

After my first infusion I grumbled to my physician that it had taken 6 hours, and that the package stuffer the nurse gave me recommended about a 2 hour infusion for someone my weight and age. He was surprised but responded, “Those nurses are really good. They probably have more information about the drug. I would go with what they say.” So I called the Head Nurse in the Infusion Center. She told me that the infusion rates come from the computer. “How does the computer know them?”, I asked.  She responded, “The Hospital Pharmacy Committee puts them in.” I called the Chief Pharmacist, noted the difference between the package insert and the computer recommendations, and asked him to review the information because I would sure like to spend just 2 hours off my boat rather than 6 for the next treatment. He contacted me a couple of days later to tell me that that medication infusion rate had been entered into the computer several years ago and was based on data from the one manufacturer of the medication. “There are now three manufacturers and two different concentrations. Each one has different infusion rates. Yours could go in over 2 hours. I will take care of updating the computer’s recommendations for your medication before the next treatment.”

The Institute of Medicine describes a medical error as “following a wrong plan of care or not completing a correct plan of care”. My computer-associated medical error was caused by “failure to update reference information”.

Do computers cause errors? The FDA maintains a data-base that categorizes voluntarily submitted adverse events associated with thousands of medical devices. Only five of the categories have the word “computer” in it. The Huffington Post made a considerable effort to analyze the most recent year’s findings in this data base and found 237 incidents that were related to health information technology. (1)

Six deaths were associated with computer adverse events. Except for two hospital-wide computer system crashes which delayed medications (both in 2006 in Cerner installations) the events included well recognized causes of NON-computer medical errors: delay in sending an x-ray image to another facility, a physician missed reading a significant “addendum note” on another physician’s progress note, an incorrect patient identification on an xray film, and an incorrect mixing of a chemotherapy solution.

Forty-three injuries associated with computer adverse events were reported. Many of these involved incorrect manufacturing of intravenous solutions rather than incorrect computer-directed delivery as well as incorrect dates, patient identification, or study type in radiology filing systems (PACs). These radiology “errors” became “injuries” when the errors were not perceived by human readers using multiple display screens, multiple screens,  screen short-cuts, etc.

Studies to date of computer errors in clinical care have by and large identified the computer/human interface as the most frequent cause of error: transcription errors, misreading of displays, mis-navigation among screens,  ignoring alerts, overriding warnings or alerts, failing to update reference and resource information. It is comforting to know that very few of these have led to harm because most of these are recognized as errors by trained clinicians before harm occurs. There is little data currently to suggest that we are just seeing the “tip of a gigantic iceberg.” Even the harshest critic of UK’s attempt to implement a nationwide EHR has been focussed on the business plans, difficulties of implementation, and cost. (2)

Several years ago a banker spent a day shadowing both an internist and a surgeon at our hospital as part of a Doctor-For-A-Day program and summed up his impression as: “A doctor’s  job seems to be a day-long search for credible data.” As long as we have well-trained clinicians providing our care, the help that computers will give them, and us as patients, in finding credible data will far out weigh any of the “new-found errors” (3) that will surely emerge as the new technology is implemented. The greatest threat to medical safety from computers will come from our trust in them, thinking that they are always right. A vigilant, skeptical clinician, and patient, is still the best defense against any subsequent harm from “computer error”.


1. The Health Care Blog, “Do EHRs Kill People”, June 11, 2010, Margalit Gur-Arie
2. http://hcrenewal.blogspot.com/ – Health Care Renewal – a blog “addressing threats to health care’s core values, especially those stemming from        concentration and abuse of power”.
3.National Research Council, January 2009

Vol. 25 July 15, 2010 “Meaningful Use” of Electronic Health Records (EHRs)

July 15, 2010

Incentive payments via Medicare and Medicaid reimbursements to hospitals and clinicians for implementing electronic medical records under the 2009 HITECH Act (Health Information Technology for Economic and Clinical Health) require the “meaningful use of EHRs to achieve specified improvements in care delivery”, not just adoption of a hardware and software system.

On July 14, 2010 the ONC (Office of National Coordinator) of HIT (Health Information Technology) of DHHS (Department of Health and Human Services) released “The Final Rule” of “meaningful use” criteria/regulations that will have to be met by both hospitals and clinicians to receive HITECH incentive money.

Number of pages of regulations/criteria in “The Final Rule”:  846

Number of years The Final Rule will actually “rule”: 2

  • The Final Rule is no where near “final”. It will merely govern the first two years of HITECH incentive payments and will be revised as the ratcheting up of EHRs standards and implementation occur over the 10 years covered by the HITECH Act.

Total amount of money estimated to be paid out over the 5 years of HITECH incentives: $27 Billion

Amount per clinician estimated to be paid out for HITECH incentives over 5 years by Medicare and Medicaid respectively: $44,000 / $63,750

Deadline for EHR implementation by clinicians to obtain the maximum incentive payments: October 2011

Year in which incentive payment is replaced by a reduction in reimbursement rates (“penalties”) for hospitals which have not implemented “meaningful use” of EHRs : 2015

Number of core measures (“data elements”) that are mandatory for “meaningful use”: 15

  • These measures are basic identification and demographic data elements that are essential to any medical record and represent a reduction from the original 23 measures. (ex. vital signs, allergies, medication list, problem list, smoking history, etc.)

Per cent of patient EHRs that must have these mandatory measures by 2011:  30 – 80% depending on the data element

  • This represents a major change from the initial draft that called for 100 % compliance in the first two years.
  • CPOE (computer provider order entry) will be required only for medication orders and the compliance threshold will be at least one CPOE medication order for 30% of the patients.

Number of optional measures to be chosen by the clinician or hospital for inclusion: 5 out of a list of 10

  • Ex. incorporate lab data as a structural data element, produce summary of care for referrals or transfers, summit immunization data to registries, etc. Many of these also have less than 100% compliance requirements.
  • Recording of advance directive status (Health Care Proxy) in 50% of patients 65 years or older is one optional measure specifically for hospitals.
  • Patient access to their records via PHR (Personal Health Record) or a Patient Portal is NOT a listed criteria yet.

Number of quality measures that are mandatory under HITECH to report to DHHS electronically in 2011-12: 6

  • The three mandatory ones, blood pressure level, tobacco use, and adult weight screening, and three additional ones chosen by the clinician from a myriad of “quality measures” represent a marked reduction in the “burden of quality reporting” contained in the initial draft.

Number of Regional Extension Centers to be established by DHHS to help hospitals and clinicians implement EHRs:  70

  • See article by Atul Gawande, MD proposing the application of the successful agricultural “extension agents” model of 1914 to health care reform of 2010 in New Yorker magazine 12/14/09. See also Alain Enthoven’s critical rebuttal of the model in Health Affairs 12/22/09.

Words from the letters of the acronyms of EHRs, ONC, and HIT:   “RECON THIs”

  • Loose translation: Keep your eyes posted for many future developments.
  • Also, better than “CHRIsT, NO!”

1. Health Care Blog, July 14, 2010, “Meaningful Use” Margalit Gur-Arie
2. NEJM online, Health Care Reform Center, “Meaningful Use Regulations”, July 13, 2010, David Blumenthal

Vol. 17 March 15, 2010 Do You Know What Medicare Pays Your Doctor?

March 15, 2010

During the health care reform debate all sides trumpeted the need for transparency in health insurance economics and provider reimbursement (payments) as essential for us to understand health care costs.

Have you ever tried to figure out the Explanation of Benefits (EOB) health care insurance companies send you? Each EOB itemizes the care you have received from all providers and the amount the insurance company reimbursed (paid) them. Had any success in understanding it?

As a practicing physician I often did not know what I was going to be reimbursed (paid) until I got the EOB accompanying the check from the insurance company (or Medicaid). Even after 35 years of practice it was nearly impossible to accurately predict my reimbursement (pay) for services to patients because of changing codes, new codes, changing regulations, etc.

I figured that now as a patient any EOB I got listing all my providers and what the insurance company reimbursed (paid) them might be a lot easier to understand. Alas, the lack of transparency is apparent from this side of the fence too.

When I received a Medicare (MC) EOBs about my August 2009 “illness episode” I spent considerable time  trying to make sense of them. It was difficult, and I am in the business! I had to pay strict attention to small letter footnotes (a through g), tiny asterisks, long and complex identifier numbers, far-flung-but-important sidebar boxes, and, of course, the always important and easy to miss “other side of the page”. I was able to develop a “translucent” picture at best; think “smoke and mirrors” as the operative term, …and the effort raised more questions than it answered.

Let me share with you a brief summary with as little chaff as possible.

In August I went to my community hospital ER with fever and vigorous chills, teeth chattering rigors. I was in the ER for 6 hours for diagnostic tests and intravenous treatment.
.                                  Hospital charges: $2,564           MC paid: $660.21

  • Of 27 medical care items listed, all but 5 were paid at 100% of the “MC approved amount” whatever that is. It is not on the EOB, and we have no access to those MC approved amounts. Even if we did we would know them for one state only. Even though MC is a federal program its approved rates vary by state and sometimes even by county within a state.
  • MC reimbursement rates are calculated using, among other factors, “how much MC spent for medical care per person in your region last year”. If  MC spent less per person in your region than other regions last year MC reimbursement in your region this year will be lower. The amount spent per person last year might be lower than others because of better health,  less utilization of medical care, or more efficient use of resources. Hence, the phrase, “no good deed goes unpunished.”
  • The 5 items not paid at the “approved rate” were ER visit ($804 charge), IV antibiotics ($332 charge), Chest x-ray ($175 charge), and EKG ($122 charge) for total charges of $1,433. All lab charges except $22.75 for a prothrombin test which was “not a covered service” for some unknown reason were paid at “approved rates.” The EOB does not make it clear what the  $660 payment of the $2,562.44 charges was exactly for.
  • In January 2010, 5 months after my ER visit, I received a phone call from Blue Cross (my state’s MC intermediary) asking me if I had, in fact, received a chest x-ray ($175 charge out the $2,564 total)  in the ER and…WHY did I think I got it?!  I am still perplexed about that call. The caller knew me as a patient, not as a physician.

The physician charges and approved and paid amounts for the same ER encounter were:

ER physician –                         $236 charges     $115.58 approved     $92.46 paid by MC
Cardiologist visit in ER –        $206 charges       $61.92 approved      $49.54 paid by MC
Cardiologist reading of EKG later –       $27 charges   $9.24 approved     $7.39 paid by MC
Radiologist reading chest x-ray later –  $38 charges   $11.46 approved     $9.17 paid by MC

  • Total physician charges: $507         Total MC paid:  $158.56

Two weeks later I had a CT scan of abdomen and pelvis looking for the source of the bacteria in my blood that had caused my symptoms.

Hospital CT scan charge:             $4,090     approved rate not listed     $588.96 MC paid
Radiologist reading the CT scan charged:  $425     $127.59 approved    $102.07 MC paid

  • Which number is the correct one? Did the scan really cost $4,090 to perform? Why does MC think it is only worth $588.96 or 15% of what the hospital thinks it is worth? Who decides? Is that what the health care reform debate is really about?
    In this case, the patient considered the scan “priceless”.
  • Next time you see an ad for a CT scan or MRI at half the price (charge) of a hospital remember that the charge can be anything. What the facility actually gets paid is up to MC or other insurance company. Marketing your lower price (charge) makes sense when your reimbursement may be completely independent of the charge.

I have to refrain from discussing co-insurance, deductibles, supplementary insurance coverage, coordination of benefits, and the meaning of “you may be billed” on the EOB because I have run out of space, and your eyes are glazing over, and…DON’T START ME  on  primary care reimbursement!

Vol. 16 March 1, 2010 What’s Good for Your Heart? Less Salt, Less Fat…or NOT?

March 1, 2010

Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs
and should be a public health target” (1)
– New England Journal of Medicine, Feb. 18, 2010

.“The human body is very adaptable. When you drink water and ingest salt your kidneys
keep what you need and excrete the rest.” (2)
– Nathan Talbot, MD, 1969, Harvard Professor of Pediatrics,
expert  in research in life-raft survival physiology

“Whether or not salt is bad for your health is still controversial. One camp says that salt is part of eating healthy.
The other says that salt causes high blood pressure, strokes, and heart attacks. Both may be right.”
– Salt: A World History, Mark Kurlansky, Penguin Press, 2002

First known warning that salt could lead to high blood pressure and  a stroke: 600 AD, “Yellow Emperor’s Classic of Internal Medicine” (3)

Date that American Medical Association Newsletter cautioned that the “average American consumes two to three times the recommended amount of salt”: Dec. 24, 2007

Average salt consumption per day of American men and women in 2005-2006 respectively: 10.4 grams / 7.3 grams

  • “Eating that much salt is not a problem for people with healthy kidneys. The research supporting a reduction in salt [to reduce cardiovascular disease] is far less consistent than that supporting weight loss, smoking cessation, and exercise.” Hillel Cohen, MD, Albert Einstein College of Medicine (4)

Daily intake of salt recommended for healthy adults by U.S. government:  5.8 grams (a little over 2 teaspoons)

Recommended salt intake limit for adults over 40, blacks, or people with high blood pressure: 3.8 grams (about 1 1/2 teaspoon)

“Ideal” limit of daily salt intake according to the president of the American Heart Association because “everyone is at risk for heart disease”: less than 1/2 teaspoon (4)

Estimated amount of reduced annual health care costs in U.S. if salt intake was reduced by 3 grams ( about 1 teaspoon) a day: $10-24 Billion (5)

Number of big, basic assumptions that this figure is based on: 2

  1. salt reduction lowers blood pressure
  2. lower blood pressure lowers risk of stroke and heart disease

Per cent of salt in the U.S. diet that comes from added salt at the table: 20%

Per cent of salt in U.S. diet that comes from processed food: 80%

Year that Morton Salt Company added magnesium carbonate to salt to make it pour more easily: 1911

  • Who can forget that little girl under the umbrella? “When it rains it pours.”

Year that a book boosting sea salt reported that salt companies REMOVE magnesium from salt to make it flow more freely and to make money selling the magnesium: 2005 (6)

“There is no significant evidence for concluding that dietary saturated fat is independently associated with an increased risk for heart disease… Specific nutrients used to replace saturated fats may not reduce, and may increase, risk of cardiovascular disease. More data is needed to elucidate those effects.” (7)

Number of studies/subjects/years of followup reviewed by this mega-analysis to support the above quotation: 21 studies / 347,747 subjects / 5-23 years  (7)

Number of grams of sugar and calories in a cup of LOW-FAT fruit flavored yogurt: 46 grams sugar / 233 calories

Number of same in a cup of WHOLE MILK yogurt (contains fat) with unsweetened frozen berries: 24 grams sugar / 230 calories (8)

1.Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease, NEJM 362;7, Feb. 18, 2010, 590-599
2.Personal communication from the “Chief” to us pediatric residents
3. Salt: A World History, Mark Kurlansky, Penguin Press, 2002
4. The Salt Shake, Kenneth Weintrub, Boston Globe, Feb. 1, 2010, G 4
5.Compelling Evidence for Public Health Action to Reduce Salt Intake, Editorial, NEJM 362;7, Feb. 18, 2010, 650-652
6.Sea Salt’s Hidden Powers, Jacques de Langre, PhD, 2005
7. Am J Clin Nutrition 91:535-546, March 2010, R. Krauss, et al.(online Jan 2010)
8. Boston Globe, Feb. 24, 2010, A. Boomer, G21

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