healthy4u: Cleveland Clinic

Electronic siloing: An unintended consequence of the electronic health record - Cleveland Clinic Journal of Medicine

EHR systems have largely been designed by those of a manufacturing, mercantile, and management computing background, largely due to abdication of responsibility and acquiescence by medical professionals, and political impotence of organized medicine and medical informatics organizations. The results were predictable - a toxic effect on healthcare.  One such toxic effect is an impairment of essential communications between caregiving personnel - exactly the opposite effect the hundreds of billions of dollars spent on today's health IT was intended to improve. <blockquote class="tr_bq">From the Cleveland Clinic Journal of Medicine: <a href="http://www.ccjm.org/content/80/7/406.full">Electronic siloing: An unintended consequence of the electronic health record</a> July 2013</blockquote><blockquote>JAMES K. STOLLER, MD, MS Chair, Education Institute; Staff, Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic; Jean Wall Bennett Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, OH For all the purported benefits of the electronic health record (EHR), an unintended adverse effect is “electronic siloing.” I define electronic siloing as the isolating effect of the EHR on clinical workflow that drives caregivers to work in silos, ie, alone at their workstations, thereby discouraging spontaneous interaction. To the extent that increasing evidence supports the importance of interaction among clinical colleagues and of teamwork to optimize clinical outcomes, electronic siloing threatens optimal practice and quality.</blockquote> Not only does it "threaten" optimal quality, it causes that quality to deteriorate to the point where a recent volunteer study at 36 hospitals by the renowned ECRI Institute (<a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a>) found more than 170 health IT-related mishaps in a mere 9 weeks, 8 of those incidents resulting in patient harm and 3 possibly contributory towards patient death. <blockquote class="tr_bq">... THE EHR BRINGS CHANGES, GOOD AND BAD [the latter especially from bad health IT - ed.] The EHR represents a major change in health care, with reported benefits that include standardized ordering, reduced medical errors, embedded protocols for guideline-based care, data access to analyze clinical practice patterns and outcomes, and enhanced communication among colleagues who are geographically separated (eg, virtual consults). On the basis of these benefits and the federal Medicare and Medicaid financial incentives associated with “meaningful use,” the EHR is being increasingly adopted.</blockquote> The literature supporting those benefits is scarce, of poor quality, and refuted by other literature by credible authors - not the optimal environment to justify spending hundreds of billions of dollars (e.g., see <a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html">http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html</a>). <blockquote class="tr_bq"> Yet for all these benefits and the promise that technology can enhance interaction among health care providers, unintended risks of the EHR paradoxically threaten optimal clinical care.6Recognized risks include the threat to care should the EHR fail, the time and inefficiency costs of typing and multiple log-ons, and the perpetuation of errors in the medical record caused by the cutting and pasting of clinical notes.</blockquote> To name just a few, all covered on this blog in various posts. <blockquote class="tr_bq"> ... Niazkhani et al noted that computerized ordering can change communication channels and collaboration mechanisms. More specifically, they point out that these systems can “replace interpersonal contacts that may result in fewer opportunities for team-wide negotiations."</blockquote> This is, in fact, obvious to any practicing physician or nurse and requires no academic "proof." <blockquote class="tr_bq"> Similarly, Ash et al cited the unintended consequences of patient care information systems, especially increased overreliance on the system to communicate, which can undermine direct communication between healthcare providers ... Taken together, these observations suggest that the EHR and computerized order entry in particular can disrupt interaction between physicians and other health care providers, such as nurses and pharmacists.</blockquote> Similarly, that this needs to be stated in 2013 is akin to stating that it's a good idea to use sterile technique in surgery. <blockquote class="tr_bq"> ...  the EHR can inadvertently lessen spontaneous interaction between physicians as they care for outpatients. I have proposed the term electronic siloing to reflect the isolating impact of the EHR on clinical workflow that drives caregivers to work alone at their workstations, thereby discouraging spontaneous interaction between colleagues (eg, between primary care physicians and subspecialists, and between subspecialists in different disciplines). Because spontaneous face-to-face encounters and conversations among clinicians can encourage clinical insights that benefit patient care, electronic siloing can undermine optimal care. My thesis here is that the EHR predisposes to electronic siloing and that the solution is to first recognize and then to design care to prevent this effect.</blockquote> The solution is first to force the industry and its pundits to admit the problem is poor design and hyper-enthusiasm that resulted in a premature national program for health IT diffusion, and abandon claims that clinicians are "Luddites" (see "Doctors and EHRs: Reframing the 'Modernists v. Luddites' Canard to The Accurate 'Ardent Technophiles vs. Pragmatists' Reality" at <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html">http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html</a>). <blockquote class="tr_bq">Defenders of the EHR will point out that the EHR does not preclude such face-to-face encounters.</blockquote> "Defenders of the EHR" will frequently default to fictitious and often ad hominem "blame the user" canards, since their scientific rationale for the proliferation of today's very poor systems is very weak. <blockquote class="tr_bq"> While technically this is correct, it is also equally true that such encounters are less likely because they no longer flow naturally from the workflow of writing a note side-by-side with colleagues with the films displayed nearby. Pressured for time, clinicians learn efficiency of motion and are simply less likely to leave their workstations to seek another colleague who, in turn, may be tethered to a workstation and absorbed in keyboarding and monitor-watching. The net effect is that such spontaneous face-to-face encounters are clearly less common in the EHR era.</blockquote> Again, this thinking will be countered by the hyper-enthusiasts by blaming users.  My response is that good health IT never depends on users to compensate for poor design or implementation, and there's nothing else to debate on that point. <blockquote class="tr_bq">... So, given the many clear benefits of the EHR and its current wave of adoption in health care, how can we maximize the benefits of the EHR while minimizing the adverse effects of electronic siloing?</blockquote> Reasonable suggestions follow; see the article at the link above.  The problem is that the reasonable suggestions are being proffered in an unreasonable, industry-dominated environment. The first step is political action and activism by clinicians to take charge of the clinical information technology playing field.  Until and unless that occurs, even thoughtful articles from Cleveland Clinic, Harvard, Yale etc. will simply be shelved. -- SS

Electronic siloing: An unintended consequence of the electronic health record - Cleveland Clinic Journal of Medicine

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24 Jul 2013

Atricure Settles

The march of legal settlements continues.  This time, the US Department of Justice <a href="http://www.justice.gov/opa/pr/2010/February/10-civ-115.html">announced</a>, <blockquote>Atricure Inc., a medical device manufacturer, has agreed to pay the United States $3.76 million to resolve civil claims in connection with the alleged promotion of its surgical ablation devices, the Justice Department announced today. Surgical ablation devices use focused energy to create controlled lesions or scar tissue on a patient’s heart or other organs. The settlement resolves allegations that the West Chester, Ohio-based company marketed its medical devices to treat atrial fibrillation (the most common cardiac arrhythmia or abnormal heart rhythm), a use that is not approved by the U.S. Food and Drug Administration (FDA). Atricure also allegedly promoted expensive heart surgery using the company’s devices when less invasive alternatives were appropriate, advised hospitals to up-code surgical procedures using the company’s devices to inflate Medicare reimbursement, and paid kickbacks to health care providers to use its devices. The United States asserted that by engaging in this conduct, Atricure knowingly violated the Food, Drug, and Cosmetic Act and caused the submission of false and fraudulent claims in violation of the False Claims Act.</blockquote> This settlement relates to topics we discussed back in the early days of Health Care Renewal, the convoluted financial ties beween the renowned Cleveland Clinic, its current CEO, and Atricure. In 2005,  investigative reporting published in the Wall Street Journal revealed the complicated relationships among the Clinic, its current CEO Dr Toby Cosgrove, the Clinic's venture capital fund, Foundation Medical Partners, and a small medical device company called Atricure. This coincided with the Clinic's firing of Dr Eric Topol from his leadership positions there. (See posts <a href="http://hcrenewal.blogspot.com/2005/12/one-horrible-debacle-indeed-topol.html">here</a> and <a href="http://hcrenewal.blogspot.com/2005/12/was-topol-fired-for-investigating.html">here</a>.) The Cleveland Plain Dealer uncovered more conflicts, involving Dr Cosgrove, the Clinic's board of trustees, Dr Bernadine Healy, and Invacare (see post <a href="http://hcrenewal.blogspot.com/2005/12/topol-merck-cleveland-clinic-case-gets.html">here</a>.)  In response, in 2006, the Clinic promised to revise its conflicts of interest policy, and held a big conference on the topic of conflicts of interest, although some were skeptical of these efforts (see post <a href="http://hcrenewal.blogspot.com/2006/05/cleveland-clinic-to-host-symposium.html">here</a>.) As the Cleveland Plain Dealer just <a href="http://www.cleveland.com/medical/index.ssf/2010/02/ohio-based_atricure_pays_38_mi.html">noted</a>, <blockquote>Cleveland Clinic Chief Executive Dr. Toby Cosgrove helped create the 'AtriClip Gillinov- Cosgrove LAA Exclusion System,' which is being sold by the company and won approval in October for use in the European market. While Cosgrove is eligible to receive royalties from the company, he has not recieved any, Clinic spokeswoman Eileen Sheil said. </blockquote> This settlement is just the latest in a now long <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">parade</a> of settlements that serve as reminders of poor behavior by myriad health care organizations.  As we have repeatedly noted, these settlements seem to have little deterrent effect on future bad behavior.  Usually, the companies involved only need to pay fines, and no individual who performed, directed or approved unethical or illegal acts will suffer any negative consequences. I submit once again that such fines are viewed merely as costs of doing business by the affected companies, and do not deter future bad behavior.  Until the people who approve, direct, and perform unethical or illegal acts pay some penalties, expect such acts to continue.  The wrinkle in this case comes from the numerous past ties between the company involved and a prestigious US health care system and its top leadership.  But I doubt that Cleveland Clinic CEO Dr Toby Cosgrove will have any public comment about it.  But why should I expect that a former company director will admit any accountability for that company's poor behaivor?  Hat tip to the <a href="http://lawprofessors.typepad.com/whitecollarcrime_blog/2010/02/in-the-news-around-the-blogosphere.html">White Collar Crime Prof Blog</a>.

Atricure Settles

The march of legal settlements continues. This time, the US Department of Justice announced,Atricure Inc., a medical device manufacturer, has agreed to pay the United States $3.76 million to resolve …

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03 Feb 2010

Diversity Nightmare And Federal Antidiscrimination Laws: Cleveland Clinic CEO Delos M. Cosgrove Would Proudly Discriminate Against Fat People

The following stunning quote appeared in the Nov. 27, 2009 Newsweek article "<a href="http://www.newsweek.com/id/224585">The Hospital That Could Cure Health Care</a>" about the Cleveland Clinic: <blockquote>[Cleveland Clinic president and CEO Dr. Delos M. Cosgrove, a former cardiac surgeon] has even taken on the most intractable driver of American health-care costs: Americans. Having already banned the hiring of smokers (a dictate enforced by urine tests for nicotine), Cosgrove declared this year that if it weren't illegal under federal law, he would refuse to hire fat people as well. The resulting outcry led him to apologize for "hurtful" comments. But he has not backed down from his belief that obesity is a failure of willpower, which can be attacked by the same weapons used to combat smoking: public education, economic incentives, and sheer exhortation.</blockquote> My thoughts come from the perspective of a former fitness-for-duty evaluator and drug testing officer (Medical Review Officer) for the regional transit authority in a very large city, and a hiring manager in the hospital and pharmaceutical sectors. I find a profoundly discriminatory statement that a hospital CEO would "refuse to hire fat people" if he could get away with it, and that he refuses to hire smokers and forces people (presumably candidates) to take a urine nicotine test, totalitarian and highly abhorrent. Nothing about smoking or obesity [except in very specialized job situations for the latter] makes a person unfit to work in a hospital. This attitude is exactly why we have federal anti-discrimination laws, to protect people from biased autocrats like this. I should add that talent apparently is irrelevant to this autocrat; if a person is overweight, this self-righteous SOB would send an applicant out the door. So much for talent management if he could get his way. One wonders if he would also send current employees who are overweight out the door - if he could get away with it. A May 2008 USA Today article entitled "Weight discrimination could be as common as racial bias" <a href="http://www.usatoday.com/news/health/weightloss/2008-05-20-overweight-bias_N.htm">here</a> made the point that: <blockquote> <div class="inside-copy">Weight discrimination, especially against women, is increasing in U.S. society and is almost as common as racial discrimination, two studies suggest. Reported discrimination based on weight has increased 66% in the past decade, up from about 7% to 12% of U.S. adults, says one study, in the journal Obesity. The other study, in the International Journal of Obesity, says such discrimination is common in both institutional and interpersonal situations — and in some cases is even more prevalent than rates of discrimination based on gender and race. (About 17% of men and 9% of women reported race discrimination.) Among severely obese people, about 28% of men and 45% of women said they have experienced discrimination because of their weight. "Weight discrimination is a very serious social problem that we need to pay attention to," says Rebecca Puhl of the Rudd Center for Food Policy and Obesity at Yale University, a co-author of both studies. ... Institutional discrimination involved health care, education or workplace situations, such as cases in which people said they were fired, denied a job or a promotion because of their weight. Interpersonal discrimination focused on insults, abuse and harassment from others.</div> </blockquote> This raises several questions: <ul><li>The CEO of an organization sets the tone. What does such a statement about "fat people" do to staff morale?</li></ul><ul><li>As a result of this CEO's stated preferences, is there subtle or covert discrimination against overweight employees at the Cleveland Clinic, preventing promotions and/or causing or contributing to situations of <a href="http://www.answers.com/topic/constructive-discharge">constructive discharge</a>?</li></ul><ul><li>Is there subtle or covert hiring discrimination against overweight candidates, with the hiring managers knowing the CEO's expressed views? </li></ul><ul><li>One also wonders if this CEO has similar attitudes towards gays, minorities, and people with physical and emotional disorders that also would not affect their ability to perform their jobs.</li></ul><ul><li>How well does the Cleveland Clinic respect other aspects of diversity considerations in its hiring, firing, and job promotion practices?</li></ul><ul><li>What kind of care and quality of staff interactions do overweight people receive/experience at the Cleveland Clinic?</li></ul> This CEO will not be "curing healthcare" any time soon IMO, since a primary consideration is compassion. He seems somewhat deficient in that attribute. He also seems deficient in the characteristic known as business wisdom, especially in an era of competition and trigger-finger litigation. His statement could be used by competitors to steer people away from the Cleveland Clinic and its affiliates. It could very likely also be used in support of discrimination lawsuits against the Cleveland Clinic and its affiliates by current, former, and potential employees (as well as by overweight patients, conceivably) which can be very expensive and damaging to an organization's reputation. In addition to all of the problems exhibited by healthcare leaders as covered on this blog, I add a new one apropos to this CEO's cerebral anatomy: <a href="http://thesaurus.reference.com/browse/fathead">fathead</a>. -- SS

Diversity Nightmare And Federal Antidiscrimination Laws: Cleveland Clinic CEO Delos M. Cosgrove Would Proudly Discriminate Against Fat People

The following stunning quote appeared in the Nov. 27, 2009 Newsweek article "The Hospital That Could Cure Health Care" about the Cleveland Clinic:[Cleveland Clinic president and CEO Dr. Delos M. Cosgr…

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01 Dec 2009

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