HITECH Editorials in the NEJM...

Since my Labor Day message to colleagues dovetails so well with these editorials, I did not want to miss the opportunity to comment on them.  They appear to be written by people with policy interests in this information technology takeover of clinical medicine.  They are mildly critical but totally miss the mark on what a catastrophe this government roll out has been.  The question any taxpayer should ask is why any other outcome would be expected.  Software and network implementations world wide and at the level of the US government have led to colossal failures.  Multibillion dollar investments  that at some point were abandoned.  The only difference in this case is that the government is not the actual client.  The federal approach to health care - apart from the brief foray of FBI agents raiding physicians offices to see if they made any coding violations is to set up payments for proxies and let them hash things out with providers.  The primitive approach of marginal incentives that are really weighted as penalties is supposed to facilitate the whole mess.  The mess would get implemented either way if you ask me.  There are tens of thousands of executive and mid level health care executives chomping at the bit for a project like this to mismanage.  And they have mismanaged it well.  Government leverage makes it difficult to refuse.

The initial editorial by Washington and  co-authors (1) focuses on the success of getting hospitals and physicians on the electronic health record (EHR).  They present a graphic showing the steep increase in EHR use over the 2004 to 2015 decade.  The acute care hospital curve ends at essentially 98-100% for certified EHRs and office based practices are at 90%.  The article rightly points out that physicians have borne the brunt of the implementation and how physicians are frustrated by the lack of "actionable information generated by these systems".  The article discusses the need for the "seamless flow of electronic information" in a couple of places.  It describes how EHR could be useful in research.  It ends  on a vague note that there is still a lot of work to be done and maybe that will happen some day.

The second piece by Halamka and Tripathi (2) starts out on a more realistic note.  Top down implementation gave physicians inadequate tools and then blamed them for being reluctant.  Technically physicians were not reluctant because they did not have a choice.  In most systems, administrations made all of the purchasing decisions, overhyped the software, and let it be known that contrary opinions were never appreciated.  It was up to physicians to learn how to use the stuff no matter how time consuming it was.  They point out that some measures were enacted on top of the clinical workload that made the situation worse.  They include the longest sentence I have recently seen in a journal article but it does cite a fair number of the problems a lot of the problems:          

"Soon physicians were expected to provide high-quality and empathic care in a 12-minute visit while weaning themselves from paper-based workflows, entering the numerous structured data elements required for meaningful use, rolling out new HIPAA privacy notices, implementing security protections for new electronic data, learning and incorporating new ICD-10 billing codes, and convincing their patients to use patient portals and secure e-mail, all while avoiding safety and malpractice issues." (p 907).

At one point they make the argument that health care organization have moved to "value-based purchasing".  Was that applied to the EHR?  Is there anyone today who would suggest that any EHR that is currently sold in this country is a value based proposition or is there as a result of HITECH legislation?  In their conclusion they suggest that now all of these systems are installed - the government can afford to pull back simplify requirements and let market effects shape some of the metrics like interoperability.  They suggest that returning control to the customers is a path to "recapturing the hearts and minds of our clinicians."

The government heavy aspect of these editorial pieces cannot be denied.  It is more of the same "we are from the government and we are here to help you whether you want us to or not."  Here are a few aspects of this roll out that the HITECH legislation either missed or made a lot worse:

1.  Incredible cost - 

Enterprise wide systems are incredibly expensive both upfront and for the annual licensing and maintenance fees.  That does not include any modification of the system - that will typically cost more.  Once a health system has bought in - it is difficult to shop around and come up with a better deal.  In some areas one company has a monopoly on the enterprise.  In many cases the systems are marketed as being a lot more easy to use than they are.  Support is huge in the implementation phases and drops off in a hurry.  Subsequent modifications - even if they are easy to make cost large sums of money.  In some cases the vendors demonstrate whiz bang technology like seamless integration with voice recognition systems.  The customers often find out that those options don't work well with their systems or are available as a high priced option.

In many organizations the EHR budget (combined with other federal costs cutting measures) is a fixed drain on the budget.  If revenues fall, lay offs can occur just to keep the EHR running.  In private practices, the up front and monthly licensing fees are no less of a burden.  There are some "free" EHRs that are funded by advertising or research but no standard comparison or guidance for any clinic that needs to implement one.  The total budget of these costs would be interesting to see, but I have never been able to find a good reference.  Health systems typically describe their margins in the low single digits.  If that is true and EHR system costing tens of millions up front with tens of millions in maintenance costs is clearly a tremendous drain on the system.

2.  IT implementation is poor -

I don't know what percentage of physicians has seen their EHR rolled out in a way that does not optimize clinical utility.  Working physicians need the most rapid route to incorporate the EHR into their work flow.  That includes software that works, software that is efficient, and ideally software that is smart enough to allow individual physicians to analyze trends in the same patient or groups of patients that will allow better diagnosis and treatment.  The IT implementation is also frequently biased toward administration rather than clinicians.  Many clinicians are surprised to find that someone is counting their mouse clicks as a way to measure productivity and the EHR charts they access are monitored.  This is another significant cost that nobody ever seems to discuss. The most egregious implementation error is when a software change is made on the fly and the physicians are given a heads up with no training.  They are expected to learn the software change with no training.  I have always found the illusion of assistance with the EHR interesting.  For the first few months there are always superusers and the factory reps clamoring to help you out.  They gradually fade into the background and you are left with a very poor piece of software.          

3.  Software quality is poor - 

As far as I can tell current EHR programs are designed to deliver lab and imaging data, generate documentation and reports, and perform a billing and coding function.  They do a fair job with the labs and imaging details. Documentation is very labor intensive and poorly done.  It adds hours per day to the physician's work flow and has necessitated the hiring of scribes and retired physicians just to keep up with the documentation tasks.  It is common that EHRs cannot be accessed by outside physicians and when that happens - the printout sent to those physicians is poorly structured and extremely content poor.

On the authorship side - a basic goal should be to produce a document fairly quickly that appears to have been written by an intelligent being.  As anyone who has read EHR entries or reports that is not typically the case.  There are extremes at either end.  You can find notes that are basically a series of check boxes or you can find 18 page notes where the author imported everything that they could into the note because that is one of the few things (in some EHRs) that you can do quickly.  Neither approach is helpful in terms of continuity of care or developing rational treatment for a patient.  Having used EHRs for the past 15 years - I can attest to clunky editing and incompatibility with voice recognition systems as being major drawbacks.  The text fields of some EHRs only work with their own microscopic and very slow editing tools.  It is impossible to set a cursor anywhere in the field to produce the document.  Using this twenty times a day when you are used to working with functional word processors is maddening.  Some systems of care set a font that looks like it is out of the 1950s and that is how the final document appears.

Every physician was appointed (under penalty of law) to be their own billing and coding specialist.  Sure every hospital and clinic has some billing and coding specialists but today they are there basically to audit the work of physicians.  In the EHR this translates to a tedious search for the diagnoses, listing them in the right priority, and signing off on the diagnostic and billing codes.  This can take up to an additional 20 mouse clicks per encounter.  Even if you can do that in 2 minutes - times 4000 encounters per year - that equals another 133 hours per year. That is work added just to maintain the EHR.  Before the EHR, billing and coding could be completed in about 10% of the time.

All the time physicians are engaged in these inefficient EHR based practices they are hearing how the EHR is such an advance in efficiency and productivity.              

4.  Hardware infrastructure/software is running 24/7 - 

Before the modern EHR, there were a limited number of workstations per hospital and most of them were shut down at night.  Now there are thousands of workstations and storage arrays in large organizations running 24/7.  They can't be shut off because of frequent software updates.  Nursing and medical staff can easily be observed spending most of their workday at computers rather than talking with patients and families.  Before the current EHR, physician would typically look at a computer screen to review the labs and possible the MAR (record of meds given).  Now starting at a computer screen most of the time is the norm.  The EHR dominant approach has increased the electrical bill and reduced time spent with patients at the same time.     

5.  A question of security - 

There have been well publicized leaks of large numbers of patient files and more recent ransomware attacks.  Security in most software systems has historically been an afterthought.  I have not seen any specific problems with EHR software but this tip sheet from CMS points out the potential complexity of the situation.  The security problem is also more urgent for healthcare sites that are under more stringent privacy requirements like 42 CFR Part 2.    

Those are a few of my ideas about the rapid deployment of the EHR.  Unlike the authors I am very skeptical of any drastic improvements on the horizon.  If you can't make an EHR that will produce a coherent report with information content at least equal to an old admission or discharge note that is a major problem.  If you can't produce an EHR that allows for some intelligent analysis of data without going through the entire record and reading every text note that is a major problem.  Sure - access to labs is nice, but we had computer access to labs before the EHR.  Patient access is also nice, but let's be honest - it is limited and doesn't address what patients really want - quality health care.

About the only thing that I agree with the authors on is that the physician needs to be put back into the loop.  But that hides the very basic fact that physicians were intentionally taken out of the loop thirty years ago when politicians decided that they could be replaced by managed care administrators.

When you look at it from that perspective the massive problems with the current EHR - make perfect sense.

  

George Dawson, MD, DFAPA



References:


1:  Washington V, DeSalvo K, Mostashari F, Blumenthal D. The HITECH Era and the Path Forward. N Engl J Med. 2017 Sep 7;377(10):904-906. doi: 10.1056/NEJMp1703370. PubMed PMID: 28877013.

2:   Halamka JD, Tripathi M. The HITECH Era in Retrospect. N Engl J Med. 2017 Sep7;377(10):907-909. doi: 10.1056/NEJMp1709851. PubMed PMID: 28877012.

The Equifax Hack - Implications for Corporate Medicine

A couple of days ago it became general knowledge that Equifax, one of the major credit reporting agencies in the US was hacked and information on up to 143 million people was exposed.  To make matters worse, the theft occurred from the company's own identity theft monitoring division called TrustedID Premier.  Like most identity theft prevention companies they charge a monthly fee for monitoring your credit transactions and monitor credit card transactions  by number.  They generally store more personal identification information than is found on a typical credit report.  According to Bloomberg financial news Social Security numbers, addresses, driver’s license data, and birth dates were available to the hackers.  It took a few days but the agencies eventually picked up on the fact that Equifax was going to provide a year of free credit protection in return for a waiver that the person getting the protection was not going to sue the company.  The Bloomberg piece quotes an attorney saying that Equifax could be facing and $70 billion in claims and a multibillion dollar class action lawsuit has already been filed.  It goes on to point out that the consumers are limited by arbitration, but in practical terms they are also limited by the sheer scope of trying to collect damages from massive corporations.

I have followed consumer reporting since it all started back in the 1970s.  Originally it was just one company and the data was held in a safe.  With the evolution of information technology in the 21st century the landscape has evolved into three national credit reporting agencies Equifax, Experian, and TransUnion.  There are longstanding concerns about the accuracy of the data they keep in credit reports, the rating system, consumer access, and dispute resolutions.  The fact that all of the information is stored under Social Security Number identifiers is significant for two reasons.  One is the promise that Congress made to the American people when Social Security was introduced - the the Social Security Number would never be used as a national identifier.  At the most it would be used within the government for identification purposes.  Today all credit reporting information is linked to SSNs and the numbers are bought and sold on the black market by the tens of millions.  Reason two is that this is this wholesale loss of control over the SSN has been the single most important cause of identity theft.

According to the US Department of Justice - 17.6 million people or about 7% of the US population over the age of 16 was a victim of identity theft in 2014.  Although half of these incidents are rapidly resolved with minimal losses the scope of the crime results in total losses to victims of $15.4 billion.  The DOJ study shows that social consequences of the theft (life stress) are a direct correlate with the length of time that it takes to resolve the incident.  Commercial losses are estimated to be about twice of the loss to victims.  The typical way that a victim of identity theft learns about the problem is that they are notified by a business.  There is no standard protocol for dealing with the problem.  A minority of people report it to the police and if they do they are likely to receive a police report number.  Businesses in general were very lax in doing anything about the theft.  The usual recommendation is complete the affadavit that the consumer did not take the money himself, but now hacking and identity theft is so common that the federal government has a special website to be of assistance called IdentityTheft.gov.

Most Americans would find that the wholesale facilitation of identity theft would be infuriating enough on its own merit.  But consider for a moment that they general processes that resulted in this problem are generally applied to any number of businesses including health care.  A few of the common points are listed in the table below.  The only possible difference is that data breaches of health care systems are much more common.

Industry	Credit Reporting	Managed Care
Invented by Congress?	Yes	Yes
Protected by state and federal laws and regulations?	Yes	Yes
Use Social Security Numbers as unique identifiers?	Yes	Yes
Legally mandated limits on privacy?	Yes	Yes
Mandated use by every citizen – no opt out?	Yes	Yes
Civil Liability limited by law?	Yes	Yes

The parallels are uncanny and the results are the same.  Large protected industries that at some level can trade in consumer privacy and generally act with impunity.   Like the explicit and implicit protections against lawsuits that the credit reporting industry has - the managed care industry is protected from lawsuits by ERISA.  Managed care companies themselves can essentially do what they want in terms of reimbursing doctors, paying for medications, setting rates and copays.  They set their own standards and advertise these standards as quality.  The real quality these businesses add is negligible to less than negligible. To get treated in these systems prospective patients need to agree to play by all of these limitations including the fact that medical and private information will be released to any payers and "protected entities", including companies that may be interested in selling the patient a product to treat one of their chronic illnesses.

I never cease to be amazed at how passive Americans are when it comes to allowing elected officials to barter way their privacy rights and money to businesses.  The credit reporting industry did not exist before a few entrepreneurs convinced Congress it was a good idea and and the legal and regulatory landscape was set to to favor those businesses to the point that they are essentially monopolies.  With few exceptions, the consumer needs to pay for the information that they are collecting on him or her if they are interested in the reports and then again if they are making a significant financial deal.  They are not allowed to opt out of a system that puts them at risk all of the time.  It is easy to see how these systems engender a fatalistic and in some cases nihilistic attitude in many Americans. 

That is not likely to change until elected officials stop treating their citizens like they are cannon fodder for the businesses they invented in the halls of Congress.      

George Dawson, MD, DFAPA




Reference:

Polly Mosendz and Shahien Nasiripour.  Equifax’s Hacking Nightmare Gets Even Worse For Victims https://www.bloomberg.com/news/articles/2017-09-08/equifax-s-hacking-nightmare-gets-worse-thanks-to-arbitration-clause  September 8, 2017, 6:38 PM CDT



Attribution:  Graphic at the top dowmloaded from Shutterstock per their standard agreement.  Artist is TippaPatt  - labelled as: "Digital alarm icon and low angle view modern office buildings in blue tone with network connection concept, smart city and wireless communication network, IOT internet of things conceptual image."


Supplementary:

Jerri-Lynn Scofield.  Wolf Richter: Worst US Consumer Data Hack Ever? Equifax Confesses.  naked capitalism.  September 11, 2017.

Good article on how to protect yourself from the Equifax hack and a good quote on how to view your relationship with credit reporting companies:

"And remember: you’re not their customer; you’re their product."

Why Most People Don't Have A Mind For Medicine

The inspiration for this post was a story I just read about the "victims" of the crackdown on opioids.  A number of chronic pain patients were described who were only able to get pain relief from opioids.  They discussed being limited to arbitrary reductions in medications or monthly limits imposed by politicians.  In some cases the people taking pain medications were being treated like criminals.  They don't like being treated on the basis of people who are addicted to opioids.  I did a more extensive search and there are several articles out there like this.  The general tone of the article is that there are tens or millions of people out there with chronic pain and that since many of them need opioids for chronic pain aren't we overdoing it a little with the restriction on opioids?  Why should good people suffer just because some addicts misbehave and die?

Some of these articles attempt a semblance of balance.  They discuss the timeline of the opioid crisis based on policy changes and pharmaceutical marketing.  They may get the opinion of some experts than generally falls along polarizing lines.  In the end the reader is generally left with a definite viewpoint on what might be the right or wrong approach to chronic pain and the opioid crisis.  There is never an explicit statement about right or wrong approaches being the way we got into the opioid crisis in the first place.  Medicine is not a a field that you can generally approach with a pre-existing right or wrong bias - at least not for the majority of patients.

Most medical care is directed at a collection heterogeneous disorders spread across the entire population.  Each of these conditions has numerous etiologies and no clear cure.  That means from a medical standpoint it typically takes a number of trials to see if something works.  Since only a fraction of the target population responds to the intervention and a significant fraction of the target population does not tolerate it - the interventions are generally seen as being weak across the entire population.  That supports odd arguments like: "Antidepressants don't work" or "Beta blockers don't work for hypertension" or "Thiazide diuretics should always be the first line medications for hypertension".

It is also very tempting to look at the entire heterogeneous population and think: "Now we have a medication that can treat everybody.  This is the magic bullet for this disorder".  There are really very few medications that work that way.  The reason for the less than robust response blockbuster drugs is quite simple - a significant number of people typically do not respond or get side effects to the point that they want to discontinue the medication.   That negative response to medication is typically the main limitation when it comes to the overall effect of a medication on any population.  In my experience about 1/7 people cannot tolerate an SSRI type antidepressant medication due to side effects.  An addition 2/7 will not get an adequate therapeutic response.  On the other hand the 4/7 of the people that respond may feel much better and notice a complete remission of depression or anxiety symptoms.  Looking at the entire population the overall effect of the medication is not robust, but that does not mean that it might not be a life changing medication for some.

Opioids present a much different landscape because in many people they reinforce their own use irrespective of whether the medication works or gives that person significant side effects.  You read that correctly.  I have had people tell me directly that they got absolutely no pain relief from an opioid but they liked taking it so much they continued to get the prescription filled.  I have had people tell me that they got significant side effects from opioid medication but they kept taking it because they liked how it made them feel.  Keep in mind that there is always a range of these effects but I have never heard people describe these experiences with SSRI antidepressants.  The mere taking of an SSRI antidepressant does not reinforce continued use.      

This is the special dilemma with opioids and all medications that reinforce their own use (benzodiazepines, stimulants).  When a person says that they need to keep taking that medication - what does it really mean?  I will be the first to admit that they may need to take the medication and have treated chronic pain patients for years who were taking opioids.  They were still in pain to some degree but they also believed the opioid was providing them with some degree of relief.  The only visible sign that they could take opioids on a chronic basis was that they did not escalate the dose and did not get additional opioids or addictive drugs from other medical or non-medical sources.  The obvious question in this case is "Why don't you just increase the dose of opioid to get rid of the pain?"  The answer is that there is no medication - not even opioids that completely alleviate chronic pain.  I have had many acute pain sufferers tell me that they did not get much relief from acute pain with opiates until the non-specific effects like sleep took over.

Another factor to consider is that most chronic pain patients who come to addiction treatment centers feel markedly better and in less pain when they are tapered off opioids and placed on non-opioid medication for pain.  People are often surprised to hear that, but based on what I just said it should not be that surprising.  If you are taking a medication that will not completely eliminate chronic pain, has a lot of side effects, and biases  you into taking it and ignoring those side effects - how can you not feel better without it?

The final piece of the equation is addiction or severe opioid use disorder.  At this stage - the problem is compounded by the fact that a person needs to take the medication in order to function on a day by day basis.  If you happen to be a person with chronic pain - not being able to function in addition to the chronic pain puts you in an impossible situation.  That is especially true if you are escalating the dose of medication in order to try to recapture the original high, cope with an emotional state,  or  get some sleep.  In many of these situations the person will find themselves "cut off" from the clinic they attend because they have exceeded their prescribed amount of medications.  Because that precipitates acute withdrawal they may seek prescription medications from a non-medical source or start using heroin.

I hope that I have been able to convey the complexity of the situation with opioids for a chronic wide scale problem as opposed to other medications for similar problems.  The stimulus for this post is the usual swing in journalistic opinion with complex problems.  I was going to title the post: "Why journalists and politicians can't practice medicine".  Complex chronic problems in medicine cannot be oversimplified into binary solutions at this point in time.  Researchers are currently developing the tools that will allow us to identify subgroups in these populations and subject people to less trial and error.  At some time in the next 10 years, I expect that we will be able to rapidly identify who might be able to take opioids in a non-addictive manner and who will not be able to.  We might even have better medications for chronic pain that are safe and non-addictive by then.

In the meantime, a rhetorical approach casting some people as victims and  others as villains is unproductive and stigmatizing.  As I tell my students it is the difference between drawing inferences about people in a large city based on the amount of addiction there.  Twenty years ago in that large city children going to school would have to walk past three or four drug dealers.  As a result urban addiction rates were much higher than rural addiction rates.  Now that the rural kids have to walk past as many drug dealers, people in rural settings are addicted to heroin and dying of overdoses.  Exposure to drugs rather then moral superiority is the limiting factor.

To do well in medicine a physician needs to have good probabilistic thinking.  A lot of that process is acquired rather than learned on a rote basis.  Errors in this decision making process are almost guaranteed, but the only real problem are the physicians who seem to error all of the time.  That turns out to be a minority of physicians.  I expect that this group has difficulty managing both the treatment probabilities and interpersonal dynamics required to treat chronic pain, recognize addiction and implement the appropriate interventions.

One thing is for sure journalists, politicians, law enforcement, and insurance companies do not do a better job than the majority of physicians.  It is a major mistake to think otherwise.        



George Dawson, MD, DFAPA    





Supplementary:

Graphic is supposed to indicate that only a physicians with direct responsibility to the patient can appreciate the complexity of the situation especially when it comes to the nuances of addiction and chronic pain treatment.  It should be apparent that complexity can not be captured by rating scales.


Attribution:

Eyeball graphic is from Shutterstock "Untitled" per their standard agreement.
  

Happy Labor Day VI

I missed my Labor Day message last year for some reason.  I must have been too burned out.  Burnout has been a big theme in the physician  community in the last several years.  It is almost like it is a new discovery or another new epidemic.  Now we have detailed comparisons of degree of burnout by medical specialty and even some country to country comparisons.  The curious phenomenon about burnout is how physicians are blamed for it.  The typical intervention is to have a "course" on how to "handle" burnout.  You know mindfulness, meditation, yoga, and time management.  There is never any focus on the fact that physicians just work too hard because they have to work free for so many people.  Managed care companies, pharmaceutical benefit managers, government bureaucrats at various levels, and their own employers have come to expect that American physicians have nothing better to do than devote their time and energy to the betterment of those collective businesses.  By that metric physicians are the most exploited employees in the USA.  There is no other group expected to work for so many businesses for free.

Don't get me wrong.  I am not saying that physicians are not paid well.  I am saying that according to the studies I read they are being paid for anywhere between 50-75% of the time they work.  Even the time that they are being paid for is deeply discounted.  What other group of professionals in the USA is expected to work on an arbitrary productivity scale that varies greatly from payer to payer and has a superimposed global budget and federal incentives and penalties superimposed on top of that?  Only physicians work in that environment.  Only physicians are expected to teach future medical professionals for free.  Another one of those cases where the the term "professionalism" can be marched out and used against you.  An example:  "You can just pick up this course for the medical students or residents.  It should not take much time and I know you like to teach.  They want you to teach."  The next several weekends (whether you are on call seeing patients or not) will be devoted to to coming up with PowerPoints.  Lectures and seminars in medicine these days don't happen without the ritualistic exchange of PowerPoints.  In the process PowerPoints get blamed.  I actually like PowerPoints if they are done correctly.  I think they are unfairly blamed when the burden to suddenly produce them is displaced onto the medium rather than the process.

But the focus of my missive today is not burnout or the root cause of excessive uncompensated work.  It is one of the sources of uncompensated work and that the the electronic health record (EHR).  The attitude toward the EHR has shifted in a direction that I have promoted for over a decade.  When the group I was working for was presented with the EHR and trained on it, I knew it was a problem from the start.  We were moving from a hospital wide system that was basically for entry of medication orders by health unit coordinators, vital signs, labs, and nursing notes.  All of the progress notes were dictated or hand entered. At the end of the day I printed out the MAR (record of medications given) for each of my patients and double checked all of the medications they were getting.  The MAR was a single page table showing all of the medications in the left margin and day columns to the right with times of administration.  It was all dot matrix printing - so not as stylish as modern printouts.

Back at the time when politicians were overhyping the EHR and how it would save the health care system hundreds of billions of dollars - I did a little experiment with one of my new hospital admissions.  I decided to read all of the outpatient medical notes to see how many significant medical diagnoses were being carried over in the EHR.  At the time we were online with the new system for about 8 years.  It took me 4 hours to find and read all of the notes from Internal Medicine, Endocrinology, and Cardiology.  There were 236 notes in all. But in the end I noticed that 10 significant diagnoses had been dropped somewhere along the line.  Nobody ever seems to want to acknowledge the complexity in medicine.  As people get older they accumulate an incredible number of medical problems and in some cases the only indication is a very long list of medications that they are taking.  They have been seeing an equally long list of physicians truncating that list of diagnoses because of time constraints.  In the EHR you eventually end up looking at a very short list and need to reproduce a comprehensive evaluation from scratch.  So much for the time savings of the EHR.  Even the politicians are quiet on that one for now.

A new EHR experiment happened to me just recently.  I still treat medically complex patients and often receive them from acute care hospitals where they may have been in intensive care units.  Since many of them were taking various psychiatric medications, I felt obligated to see what the intensivists, cardiologists, pulmonologists, and gastroenterologists all had to say about these medications and whether they complicated critical care or ongoing care of the chronic medical problems.  I want to see the results of ECGs, labs and imaging studies.  I want to know if the patient received any of their usual medications when they were in the ICU or general hospital.  Before there was an EHR all of this information was contained in about 10 very readable pages consisting of the admission note, discharge summary, MAR, and a couple of sheets including the actual ECG tracing and lab reports.

For the event in question I read through the EHR printout.  It was 48 pages long.  It contained limited data.  Blood pressure trends and readings were not printed even though that was one of the critical parameters being followed.  The physician notes were jumbled paragraphs considerably less that traditional reports.  The bulk of those notes consisted of checklists and imported data in different fonts and margins.  The appearance was chaotic.  Who uses 14 point Courier font in documents these days?  I haven't seen that since the days of the telegraph.  In that entire 48 page document there were about 6 lines in a cardiologist's note that made sense so I locked onto those for my report.

I was less optimistic about Phase Two.  I have been working in my current position for about 7 years and during that time I have requested MARs on hospitalized patients about 50 times.  I have received exactly zero.  In this case for some reason it went through.  I received a 60 page fax that was the MAR.  The patient was critically ill and delirious at one point, so there were five different infusions used in intensive care spread out across many of the pages.  The composition of the solutions were listed and the specific rates of infusion.  If I wanted to know the exact amounts that the patient received - it was up to me to figure it out.  Two critical factors from the MAR that were not evident from the EHR printout.  First, the patient was much more critically ill than described in the EHR printout.  Second, none of the maintenance psychiatric medications were given.  Total time to figure all of this out - 60 minutes.  In addition to the read of the EHR printout and interview - total time for the evaluation and report was 2.5 hours.

It is impossible for physicians to do a good job of patient care without all of the material I reviewed in this case.  On the other hand, there are few places in the USA where the physician has 2.5 hours for each new evaluation.  That is how you end up with truncated problem lists, partial medical care, and physicians staying in clinic 3 hours after everyone else has left.  Without the data there is not enough information for the physician to have a decent informed consent based discussion with the patient on the new set of risks associated with a critical illness.

The real culprit here is the fact that physicians have lost control of their profession.  We have had an overhyped, inefficient, ridiculously high-priced piece of software foisted upon us by politicians and the businesses that they support.  It is really no better than personal database software that I was using in the 1990s and that software produced a more readable and coherent report.  The only reason the software works at all is because there are a million physicians out there with work arounds and doing the uncompensated hard work necessary to keep it afloat.

There is no better topic to comment on this Labor Day.  This is my wish to all of my colleagues trying to avoid repetitive stress injuries from the mouse clicks and typing necessary to support EHRs everywhere (I had to switch to my left hand about ten years ago).

Happy Labor Day!


George Dawson, MD, DFAPA          


Attribution:

Picture is Titian's work Sisyphus in the Public Domain from Wikimedia Commons at https://commons.wikimedia.org/wiki/File%3APunishment_sisyph.jpg


         

Blood Pressure

Blood pressure is an important topic for psychiatrists and all physicians.  The prevalence of blood pressure problems especially hypertension is high in the United States and has significant associated mortality and morbidity.  Many psychiatric medications affect blood pressure and some blood pressure medications like beta adrenergic receptor blockers, central alpha adrenergic receptor agonists, and alpha-1 adrenergic receptor inverse agonists have psychiatric applications.  In addition, blood pressure irregularities are noted in major toxic reactions to psychiatric medications like serotonin syndrome and neuroleptic malignant syndrome.  Hypertension is a contraindication to the use of some psychiatric medications and parameters need to be placed for their use.  All of these considerations would seem to make it obvious that frequent and consistent blood pressure measurements should be a part of psychiatric practice - but they are not.

Various problems with obtaining blood pressures occur in psychiatric practice.  Practice settings are part of the problem.  In some clinics, depending on the resources blood pressures may not be measured at all. I have received patients from some of these clinics who were treated with medications that cause hypertension or hypotension and found that their blood pressures were never checked.  I have worked in clinics where the only way that I could obtain a blood pressure or pulse reading was if I took it myself.  I have worked in other settings where blood pressures were taken, but I had no confidence in the numbers.  I found myself interviewing the patient and trying to piece together why their blood pressure and heart rates were elevated at some times but normal in others.  The only adequate assessment of the situation is that attention to blood pressure and its measurement in psychiatric settings is uneven and may be uniformly poor.

That is why an article in The Journal of Clinical Hypertension (1) caught my eye.  In the student the authors looked at 159 medical students and how they measured the blood pressure of a simulated patient against an 11-element skillset on BP measurement.  Only one student out of the 159 demonstrated all 11 skills in simulation.  The specific tasks are listed in the article and have to do with patient preparation, positioning, and the actual measurement task itself.  Some common errors in any of these areas can lead to significant differences in systolic and diastolic blood pressure measurements.  Those errors alone especially those in cuff size selection, arm positioning and patient readiness can lead to consistent false measurements in blood pressure.  As an example, I have assessed a week or two of blood pressure measurements in the mild hypertension range and after correcting the measurement techniques found that the subsequent week was all in the normal range.  This study illustrates an unacceptably high variation in these skillsets in medical students.  I am not aware of similar studies in practicing physicians.

The second article (2) is an encyclopedic reference that is a scientific consensus statement by the American Heart Association on High Blood Pressure Research.  This reference will answer any possible question about blood pressure measurement. A valuable resource from this site was a resource that provides a very extensive list of validated home blood pressure devices. It is possible to make recommendations for accurate and cost effective devices or provide the link to patients who want to explore the possibilities.

I encourage psychiatrists everywhere to make sure that blood pressures and pulses are being taken regularly and accurately.  The buck stops with the physician doing the assessment and treatment and in my opinion it is impossible to practice psychiatry without regular blood pressure measurements.  In addition to monitoring the cardiovascular status of the patient and the response to prescribed medications it provides the opportunity to diagnose a disorder that causes significant cardiovascular and cerebrovascular disease and reverse that process.

Know the 11-element skillset on blood pressure measurement.


George Dawson, MD, DFAPA


References:

1: Rakotz MK, Townsend RR, Yang J, Alpert BS, Heneghan KA, Wynia M, Wozniak GD.Medical students and measuring blood pressure: Results from the American Medical Association Blood Pressure Check Challenge. J Clin Hypertens (Greenwich). 2017 Jun;19(6):614-619. doi: 10.1111/jch.13018. Epub 2017 Apr 28. PubMed PMID: 28452119

2: Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones DW,Kurtz T, Sheps SG, Roccella EJ; Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005 Jan;45(1):142-61. Epub 2004 Dec 20. PubMed PMID: 15611362

Both of the above links are full text.



          

Dementia Prevention And Substance Use Disorders

Dementia from Addictive Compounds

As a geriatric psychiatrist and an addiction psychiatrist, what I see happening in both professional literature and lay literature is mind boggling.  There is a clear bias advocating for the benign and even therapeutic effects of alcohol and addicting drugs.  What most articles omit is that the health effects of alcohol are limited to no more than two standard drinks per day for men and one drink per day for women.  The drinks cannot be all taken on the same day.  The limits are per day not per week.  Most of the evidence also suggests that the alcoholic beverage should be wine rather than beer or distilled spirits.  Recent studies suggest that of the 70% of Americans who drink - about 1/3 of them are probably drinking in excess of those amounts.  Doing the arithmetic that amounts to about 56 million people.  Even a low percentage of brain injury will result in a significant number of cases od dementia. Moderate to heavy drinking (3-12+ drinks/day) carries the associated risks of high carbohydrate intake and sedentary life style.  It is very common to find that moderate to heavy drinkers stop their usual outdoor activities and exercise and spend a lot of time watching television.  This can lead to obesity, glucose intolerance and dyslipidemia and in the worst case scenario metabolic syndrome.  All of those consequences lead to increased risk of cardiovascular and cerebrovascular disease.  

There are addiction risks with alcohol consumption apart from atherosclerotic heart disease. Alcohol is proarrhythmic and doubles the risk for arrhythmia.  In one large Danish study (11) they noted that alcohol intake and a history of atrial fibrillation was a risk factor for ventricular fibrillation.  Some authors view alcohol use a risk factor in preventable atrial fibrillation.  In clinical practice it is very common to interview patients with atrial fibrillation who notice that during times of heavy alcohol use they can sense that they are in atrial fibrillation and they spontaneously convert to sinus rhythm as their blood alcohol levels drop.  Atrial fibrillation is a causative mechanism for embolic stroke and associated cognitive disorders.

The direct toxic effect of alcohol on the brain has been debated for years. Amnesia from Wernicke-Korsakoff syndrome is a known diagnostic entity related to thiamine deficiency associated with excessive alcohol use.  It is probably underdiagnosed in most populations compared with postmortem diagnoses of the specific lesions consistent with Wernicke-Korsakoff syndrome (WKS).  A large number of people with alcohol use problems have demonstrable cognitive effects on testing as well as structural and functional brain imaging brain imaging studies suggest some effect on brain structure.  The lack of a pathological lesion has led some to suggest that this is a non-specific effect, but it is very likely that there are several variants of cognitive dysfunction related to alcohol use that are not associated with WKS (12).  On a clinical basis it is very common to see patients with subjective cognitive impairment that typically involves working memory, declarative memory, and executive function.  In treatment setting where abstinence from alcohol is assured many of these problems seem to clear up after about 60 days of abstinence.  But there are also populations of people with varying degrees of anterograde and retrograde amnesia that is not as dense as expected with full WKS.  Many of these patients are seen in treatment settings and never referred for comprehensive assessments of their cognitive disorder.  To my knowledge there have been no studies looking at the issue of whether or not partial amnestic states correlate with WKS lesions at autopsy.        

The problems with recognizing and treating cognitive disorders associated with substance use problems are exemplified in the first few paragraphs about alcohol.  They are no less important for other commonly abused substances.  In the case of stimulants, amphetamine analogues are known neurotoxins.  Studies by Volkow and others have shown persistent changes in dopaminergic neurons up to 15 months after the last use.  This may correlate with a persistent attentional deficit that leads patients to conclude that they now have attention deficit disorder.  Additional brain insults from hemorrhagic strokes and cardiovascular problems associated with long term stimulant use are common.  Stimulants are well known precipitants of acute myocardial ischemia and brain complications from hypoperfusion and emboli.  Acute hypertension and tachycardia are part of the acute intoxication syndrome that can lead to hypertension and hemorrhagic stroke.  This recurrent cycle leads to commonly observed complications of cardiomyopathy in the 4th and 5th decades of life and heightened risk of ventricular arrhythmias and cardiac arrest.

The graphic at that top of this post is not exhaustive - but point out some significant acute and chronic complications of drug use that can lead to permanent brain injury.  These mechanisms cannot be overlooked as avoidable causes of dementia.  I will be trying to elaborate on this graphic in the future to look at developing a review in this area.  Any acute acre and addiction psychiatrist is probably more aware of these syndromes and complications because they are encountered in clinical practice.  I have not seen any formal estimates of the fraction of dementia cases are preventable by avoiding these compounds.  The largest fraction of dementia cases would likely be attributable to the most commonly used drugs - tobacco and alcohol.  Drugs that kill more people acutely on a proportional basis like stimulants and opioids probably leave fewer survivors with dementia as a complication.  

Contrary to the conventional wisdom these days - avoiding dementia is another strong argument for a sober life style.


George Dawson, MD, DFAPA


References:

1: de Gaetano G, Costanzo S, Di Castelnuovo A, Badimon L, Bejko D, Alkerwi A,Chiva-Blanch G, Estruch R, La Vecchia C, Panico S, Pounis G, Sofi F, Stranges S, Trevisan M, Ursini F, Cerletti C, Donati MB, Iacoviello L. Effects of moderate beer consumption on health and disease: A consensus document. Nutr Metab Cardiovasc Dis. 2016 Jun;26(6):443-67. doi: 10.1016/j.numecd.2016.03.007. Epub 2016 Mar 31. Review. PubMed PMID: 27118108.

Moderate consumption is defined as 1 drink per day in women and 2 drinks per day  for men in a non-binge drinking pattern. J-shaped dose-response curve

2: Fernández-Solà J. Cardiovascular risks and benefits of moderate and heavy alcohol consumption. Nat Rev Cardiol. 2015 Oct;12(10):576-87. doi: 10.1038/nrcardio.2015.91. Epub 2015 Jun 23. Review. PubMed PMID: 26099843.

U-Shaped dose-response curve

3: Matsumoto C, Miedema MD, Ofman P, Gaziano JM, Sesso HD. An expanding knowledge of the mechanisms and effects of alcohol consumption on cardiovascular disease. J Cardiopulm Rehabil Prev. 2014 May-Jun;34(3):159-71. doi: 10.1097/HCR.0000000000000042. Review. PubMed PMID: 24667667.

4: Graff-Iversen S, Jansen MD, Hoff DA, Høiseth G, Knudsen GP, Magnus P, Mørland J, Normann PT, Næss OE, Tambs K. Divergent associations of drinking frequency and binge consumption of alcohol with mortality within the same cohort. J Epidemiol Community Health. 2013 Apr;67(4):350-7. doi: 10.1136/jech-2012-201564. Epub 2012 Dec 12. PubMed PMID: 23235547.

5: Weyerer S, Schäufele M, Wiese B, Maier W, Tebarth F, van den Bussche H,Pentzek M, Bickel H, Luppa M, Riedel-Heller SG; German AgeCoDe Study group (German Study on Ageing, Cognition and Dementia in Primary Care Patients). Current alcohol consumption and its relationship to incident dementia: results from a 3-year follow-up study among primary care attenders aged 75 years and older. Age Ageing. 2011 Jul;40(4):456-63. doi: 10.1093/ageing/afr007. Epub 2011 Mar 2. PubMed PMID: 21367764.

6: Bathla M, Singh M, Anjum S, Kulhara P, Jangli S IIIrd. Metabolic syndrome indrug naïve patients with substance use disorder. Diabetes Metab Syndr. 2016 Sep 3. pii: S1871-4021(16)30183-7. doi: 10.1016/j.dsx.2016.08.022. [Epub ahead of print] PubMed PMID: 27618517

Alcohol was the main substance used by patients meeting WHO criteria for Metabolic Syndrome.

7: Vancampfort D, Hallgren M, Mugisha J, De Hert M, Probst M, Monsieur D, Stubbs B. The Prevalence of Metabolic Syndrome in Alcohol Use Disorders: A Systematic Review and Meta-analysis. Alcohol Alcohol. 2016 Sep;51(5):515-21. doi: 10.1093/alcalc/agw040. Epub 2016 Jun 23. Review. PubMed PMID: 27337988. 

1 person in 5 with alcohol use disorder has metabolic syndrome.

8: Wakabayashi I. Frequency of heavy alcohol drinking and risk of metabolicsyndrome in middle-aged men. Alcohol Clin Exp Res. 2014 Jun;38(6):1689-96. doi: 10.1111/acer.12425. Epub 2014 May 12. PubMed PMID: 24818654.

Positive correlation between heavy drinking and metabolic syndrome.

9: Yousefzadeh G, Shokoohi M, Najafipour H, Eslami M, Salehi F. Association between opium use and metabolic syndrome among an urban population in Southern Iran: Results of the Kerman Coronary Artery Disease Risk Factor Study (KERCADRS). ARYA Atheroscler. 2015 Jan;11(1):14-20. PubMed PMID: 26089926; PubMed Central PMCID: PMC4460348.

Current opioid users had the highest prevalence of metabolic syndrome (39.6%) but the study was confounded by a high baseline rate in the controls (37.2%).

10:   Brunner S, Herbel R, Drobesch C, Peters A, Massberg S, Kääb S, Sinner MF.Alcohol consumption, sinus tachycardia, and cardiac arrhythmias at the Munich Octoberfest: results from the Munich Beer Related Electrocardiogram Workup Study (MunichBREW). Eur Heart J. 2017 Apr 25. doi: 10.1093/eurheartj/ehx156. [Epub ahead of print] PubMed PMID: 28449090.

11: Jabbari R. Ventricular fibrillation and sudden cardiac death during myocardialinfarction. Dan Med J. 2016 May;63(5). pii: B5246. Review. PubMed PMID: 2712702.

12: Ridley NJ, Draper B, Withall A. Alcohol-related dementia: an update of the evidence. Alzheimers Res Ther. 2013 Jan 25;5(1):3. doi: 10.1186/alzrt157. eCollection 2013. Review. PubMed PMID: 23347747.


Supplementary:

The calculation for the following observation:

Recent studies suggest that of the 70% of Americans who drink - about 1/3 of them are probably drinking in excess of those amounts.  Doing the arithmetic that amounts to about 56 million people.

321M(current US population) - 80M (population less than drinking age) x 0.7 (percentage of population that drinks) x 0.3 percentage of excess drinkers = 56 million people.

 

Infection Disease Docs - Treating Addiction

There was a very interesting commentary in this week's New England Journal of Medicine.  In it the authors describe a case from their infection disease practice of a young man with infectious complications of intravenous heroin use ( Staph. aureus tricuspid valve endocarditis, septic arthritis, and empyema).  He had a history of doing well on buprenorphine maintenance in the past and was offered that treatment again by the Infectious Disease (ID) team as he was leaving inpatient hospital.  They completed the induction phase on the afternoon of discharge and he was discharged on buprenorphine-naloxone (Suboxone).  The ID  faculty at Beth Israel Deaconess Medical Center, a large tertiary care hospital in Boston have all been certified as buprenorphine prescribers and present this as an option to all of their patients with infectious complications of  intravenous substance use.  In addition to the buprenorphine they also provide rescue naloxone to treat acute opioid overdoses, discussions about harm reduction, injection practices, and cravings.  In the case that was presented, there was a discussion of the relapse risk and risk of recurrent infection or death from an accidental overdose.

This group of physicians has provided an outstanding example of what can be done when you are working with a highly motivated group who seizes the opportunity to make a significant difference. Part of their discussion is in terms of expanding their practice outside of the traditional role and expecting some pushback on that.   As I read their report, I thought about how this process might occur within the usual hospital setting.  A psychiatric consultation would be placed.  In tertiary centers a psychiatrist would see the patient, make a detailed assessment and recommend outpatient care somewhere.  That psychiatrist may or may not have a buprenorphine license.  Depending on location, there may not be a buprenorphine provider to refer the patient to.  In the case of intravenous heroin use that practically guarantees a relapse to heroin at the time of discharge with the attendant mortality and morbidity.  In this case the patient is familiar with the same treatment team that discusses the issue with him and gets him on Suboxone prior to discharge.  In today's world of rationed medical care - I cannot think of a more perfect intervention for high risk patients from an addiction standpoint.

The use of buprenorphine to treat opioids use disorders is not a perfect solution but it helps a large number of patients remain abstinent in general treatment populations.  The patient described in this paper was perhaps more highly motivated than most due to his complicated illnesses.  The authors experience reflects the fact that they clearly know the treatment process is complicated but view what they are doing as a bridge to long term care for opioid use disorders.  I agree with them completely.

There are a few considerations that they did not touch on that I think are important.  The personal characteristics of the physicians in this group is a major factor.   They discuss the history of their specialty as one that values social justice and public health.  They suggest this was a primary factor in allowing them to not get caught up in the stigma of treating addicts and the associated lack of resources.  I witnessed this first hand in the 1980s and 1990s when ID physicians and clinic staff were dealing with the HIV epidemic.  That went on for years before there was adequate treatment and the death toll was high.  Many ID clinics provided critical support to patient and their families during that  time.  I don't think that they ever got any recognition for that role.  Treating addiction above all else takes emotional neutrality and that was a characteristic I observed first hand in HIV clinics.        

I certainly hope that this group gets the credit for innovation and hard work that goes with this approach.  They mention a couple of other groups who have picked up on this approach.  At the same time I have concerns about how other groups may view this article.  The billing and coding system and clinic structures are generally not setup to allocate enough time to deal with two very complicated problems.  In the outpatient setting, sober homes set up to deal with the substance use and medical complications are extremely rare.  In some cases, sober homes and halfway houses refuse to accept patients taking Suboxone or other potentially addictive drugs.  It takes dedicated social work or case management staff to negotiate those problems.  It also takes some level of administrative support to know that discharging a patient as soon as possible when they are in opioid withdrawal makes little sense.

Time and burnout are also relevant factors.  The primitive state of productivity based medical administration needs to be able to accommodate this level of complex care and allot physicians enough time to provide both medical and addiction services.  I have over 20 years of experience in providing both medical and psychiatric services on inpatient settings.  Even though I enjoyed doing it - there was a tremendous time penalty associated with the additional work and that can easily lead to burnout.  If addiction care expands among specialists and generalists - they need the additional times and reimbursement to provide this level of care.

None of these considerations detracts from the accomplishment of this department of infectious disease doctors.  Taking on this additional role is especially striking in an era where patients are told that they can only discuss one problem per clinic visit with their doctors.  This approach is a shining example of the highest level of medical professionalism and my hat is off to them.


George Dawson, MD, DFAPA

1: Rapoport AB, Rowley CF. Stretching the Scope - Becoming Frontline Addiction-Medicine Providers. N Engl J Med. 2017 Aug 24;377(8):705-707. doi: 10.1056/NEJMp1706492. PubMed PMID: 28834479. (free full text).