Embedded Knowledge: Scanner Opportunity

It seems several patients who have received CT brain perfusion scans at some US hospitals have been exposed to an apparent overdose of radiation. The New York Times followed up on the story, which revealed a couple of interesting points. While the scanners have built-in features that allow lower doses of radiation, in some circumstances the scanners actually increase the dose. Oddly, the machines in question do not warn clinicians when the amount of radiation exceeds a safe threshold. Here, technology is used as a valued clinical tool, but it remains isolated from some important facts we know about its use. This lack of “self-awareness” on the part of the technology reinforces the role of people, culture and process in the data life cycle. For example:

  • With information technology, scanners (and other pieces of equipment) could record or make available to the electronic health record, the machine identity and the dose administered, so that the event can be linked to the patient for later analysis. This is as much a patient safety issue as it is one of quality reporting. It should be a simple matter to generate a list of all patients that have been treated using a particular piece of equipment. Part of the problem here is in the creation of medical device identifiers and standardized protocols for communicating among them. This work is underway, but still not completely implemented;
  • Scanners could be made to have an awareness of current guidelines for radiation dosages, and they should not operate at those levels unless deliberately overridden by the clinician. We already use information technology to check for drug interactions, and this is the same thing;
  • Guidelines should be standardized in structure and application, to ensure that there is no variance from vendor to vendor;
  • Physicians must actively participate in developing the data life cycle (from data to knowledge). If they are responsible for entering data, they have every right to expect that it is contributing to the development of better knowledge systems, which should continue to improve with each vendor update;

Technology performs as it is programmed to do. We cannot blame it for shortcomings that are the result of muddy processes. Figuring out how to do this properly involves cooperation among vendors, clinicians, the government, and many others. This is an example of knowing better (we know what constitutes a radiation overdose) but not yet having the processes in place to embed that knowledge into our clinical tools and the information systems that we will increasingly use to connect them. We must create processes that allow us to more fully trust the technology now, so that we can come to rely upon it, and build upon its role in the future.

The full NYT story is here.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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Advance Directives and EHRs

The recently unveiled final rules for meaningful use of electronic health records in the United States include as one of the objectives: “Record whether a patient 65 years old or older has an advanced directive as structured data.” It is included as one of the optional “menu set” of objectives and therefore not required as are the objectives found in the “core set.” Advance directives had been in the original, recommended set of objectives from the policy committee, which was created as part of the American Recovery and Reinvestment Act (ARRA) to advise the Centers for Medicare and Medicaid Services (CMS) on how to go about the business of determining whether or not a physician or hospital had become a “meaningful user” of technology. When the proposed rule came out earlier this year, the policy committee’s recommended objective had been eliminated. Now with the final rules, it’s back in, which is a good sign.

What’s interesting is some of the thinking behind this particular objective and how it reflects the way we approach the application of technology to our stated goals. In its discussion of the rules objectives, CMS says:

… a restriction to a more at risk population is appropriate for this measure. By restricting the population to those 65 years old and older, we believe we focus this objective appropriately on a population likely to most benefit from compliance with this objective and its measure.

Okay, let’s accept the assumption that people over 65 are statistically more likely to encounter the type of health issue that would require referencing an advance directive. Knowing that the patient has an advance directive, and noting it in the EHR,  helps the doctors and the institution make better decisions, but only up to a point. The rule does not require that systems store the content of the advance directive, so in an emergent situation, vital facts are missing. CMS says it did not require the content of the advance directive to be held in the EHR because there may be conflicting state regulations about such things. Fair enough.

But by limiting this measure to patients over 65, the rule implies that there is less benefit to younger patients. If Terri Schiavo had had an advance directive, the seven year ordeal over whether or not she should have feeding tubes removed would have been avoided. Resolving her case was costly in both monetary and emotional respects, to her family, the community, and the country. What then, is the real “risk” CMS notes in the rules? It is more complex than the risk of contracting an illness if you are over 65. When talking about advance directives, there are three dimensions to risk:

  1. Risk to the patient. Yes, older patients are more at risk to have a life threatening health issue. But by not having an advance directive, the patient risks loss of personal dignity and control over how these sensitive decisions are handled;
  2. Risk to the institution. This can be summed up as: Lawsuits, Cost, Reputation;
  3. Risk to the community. Whether it is a small town or the entire country, end-of-life care is a difficult discussion with a huge emotional component. Issues of faith, agenda and politics are brought into full view. An advance directive can keep a personal decision from becoming a public debate.

Right now the advance directive objective will only apply to hospitals and critical access hospitals (CAH). The rule will not apply to physicians because, as CMS notes:

…we believe many EPs [eligible professionals] would not record this information under current standards of practice. Dentists, pediatricians, optometrists, chiropractors, dermatologists and radiologists are just a few examples of EPs who would only require information about a patient’s advance directive in rare circumstances.

That makes sense, but by excluding eligible professionals as a class, primary care physicians are also excluded from playing a role in meeting a broader objective of having more Americans make thoughtful decisions about end-of-life care. And primary care encounters are the most logical place for these discussions and for entry into the electronic record. Instead of excluding all EPs, primary care should be included, while specialties should be excluded. Part of the problem here is that the HITECH act attempts to lump providers into broad categories of hospitals and physicians. Technology is simply “certified EHR” technology, with little allowance for the many variants already out there.

Finally, if we want pervasive changes in the system, specific to advance directives, the standard of practice must change. Physicians, especially those offering primary care, could drive this change by asking the question of all patients: “Do you have an advance directive?” Either way, the answer is recorded in the EHR, and the meaningful use requirement is fulfilled. In the short term, this benefits the institution, since it may qualify for incentives. In the long-term, it raises awareness among the general public that this is something to think about now, hopefully long before reaching the age of 65. Smart EHR vendors will include this in their systems now whether they are designed for ambulatory or inpatient care. “Meaningful use” has broader implications beyond qualifying for incentives, and this is one of them.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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Clinical Support Beyond the Interface

If one of the stated benefits of information technology is to support the physician’s decision making process, how will the physician’s role evolve as we increasingly come to rely on technology for support? This question assumes that we will continue to use technology to support, not replace the physician (or nurses or other clinicians for that matter). Until the time comes when we have managed to capture and represent all current medical knowledge through technology, the physician is likely to remain the primary observer; technology cannot yet take histories or connect the important dots within a complex personal narrative. Meanwhile, there will be new challenges that must be understood and managed; for example:

  • We must go deeper than the clinician-machine interface, and examine whether the data we currently collect is a capable foundation for a future of sophisticated analysis and support;
  • The concept of “interface” must evolve beyond the presentation of information and related input/response mechanisms to include clinical technology’s apparent cognitive process, so that it more closely complements clinical decision making;
  • Clinicians must take leadership roles in analyzing the current interface and describing what works and what doesn’t work;

Obviously,the art of medicine will increasingly include the ability to accurately describe the patient narrative to a technical support system in a format that can be processed not only for immediate patient benefit, but in a way that can be collected and analyzed in order to build medical knowledge and eventually, better quality of care for all. Physicians, nurses and other clinicians should be at the center of this movement.

Some questions:

  1. If you are a provider, what do current systems get right?
  2. What do they miss?
  3. In what ways do current EHR systems compromise your ability to provide quality care?

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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Two kinds of thinking

Certification Rules Are In

A nice range of things to consider over the weekend: first, the final rules for the temporary electronic health record (EHR) certification program were released. If you’re reading from outside the US, this is just one piece of the giant puzzle currently being assembled here to push physicians and hospitals closer to the use of EHRs. Several years ago, the government decided that by certifying that EHR systems could do what was promised, some level of risk would be removed, and physicians would begin to adopt these systems more rapidly. Now, in order to receive financial incentives and to avoid penalties, physicians and hospitals that participate in Medicare and Medicaid programs must adopt EHRs that have been certified. With the new laws, the meaning of certification has shifted. Instead of a form of consumer support, certification is as much a required attribute of the software as whether or not it can manage various types of clinical documentation or report quality measures. Previous certifications done by the Certification Commission for Health Information Technology (CCHIT) will not be grandfathered into the new system. Instead, organizations that wish to do the business of certifying EHR systems must apply to become a certification body. This includes CCHIT.

Incentives for meaningful use of EHR systems become effective October 1, 2010 for hospitals and January 1, 2011 for physicians. Between now and then, new organizations must be deemed capable of certifying EHRs, the systems must be certified, and previously certified systems must be re-certified. The current focus in the US regarding medicine and technology centers around, and will continue for a few years to be centered around, achieving meaningful use and avoiding penalties. Meaningful use will not be determined based on how creatively a hospital or physician is applying technology for the benefit of the patient or the community. It will be determined by meeting the requirements spelled out in a checklist of functions and features. Call this “No EHR Left Behind,” as the medical community scrambles to “pass the test.”

By the way, CMS has a new site that organizes all of its EHR incentives-related activities. Find it here:


Artificial Intelligence

At another end of the spectrum, the cover feature in the New York Times Magazine Sunday asked: “Who is Watson?” This I.B.M. project created a computer that is designed to think like a Jeopardy contestant and can, on one hand, appear incredibly intelligent. On the other hand, it can completely miss the mark, which is easy to do considering the range of wordplay the game entails. It’s interesting reading, even provocative at times. It’s especially provocative when John Kelly, head of I.B.M.’s research labs says he wants to create “a medical version” of the computer for use in hospital emergency departments. Armed with what would amount to every medical paper ever written, the computer would be able to come up with rapid-fire answers to help doctors make decisions.

Cool idea, but how we get there is more complicated than that, and raises a few questions. For example:

• At what point does research become fact or “knowledge”?

• What process determines which research becomes part of the computer’s knowledge base?

• What is the “peer review” process for new ideas generated by a computing system?

• Is it ethical to ignore patient narrative solely in favor of clinical fact?

• What power will a physician retain to overrule, modify or concur?

“The problem right now is the procedure, the new procedures, the new medicines, and new capability is being generated faster than physicians can absorb on the front lines and it can be deployed,” says Kelly. This might not be the best reason to employ technology. Simply having “everything” in a database does not mean you have information. There is a fine line between using technology to distribute information we know to be helpful, and allowing technology to make those decisions for us. With the former, we remain accountable to patients and society; with the latter, we abdicate responsibility. Somewhere in the middle lies the art of medicine and technology.

The NYT article is here:


-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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