Computers & Software Medicine

Geeky Docs

I remember the disdain some of the EHR trainers had for their trainees back when our hospital system “went live” several years ago. Of course this disdain was tempered by their knowledge that if docs weren’t so computer illiterate, or the user interfaces of the EHR systems weren’t so awful, or if the EHR software wasn’t so bug-ridden, their jobs wouldn’t exist. So they soldiered bravely on, undaunted by grumpy old docs who now had to type their notes despite never learning how to touch type, who had to reconcile medication lists a mile long including meds like cinnamon that they really could care less that the patient was taking but had to be reconciled nevertheless, who had to painstakingly enter orders using an interface designed by an engineer who knew as much about medicine as — an engineer, and who were angry and resentful that this newfangled computer system was being shoved down their throats under threat of loss of government medicare reimbursement. Given the tensions and personalities involved, it still amazes me that the EHR transition was accomplished without loss of life or limb.

Maybe the classes helped. Long before the go-live date, we went to EHR school. This consisted of several days of classes, during which the world of health care delivery was supposed to stop (it didn’t) while all medical personnel sat around drinking coffee and listening to talks about how the EHR was supposed to work. Even though this was a useful education into what the life of a hospital administrator must be like, the real world of patients and disease tended to encroach on the world of mouse clicks and meaningful use butttons to the point that I skipped the last afternoon of classes and the final exam. Unfortunately my truancy was detected and, under penalty of garnishment of wages, I was forced to do a make-up class. Despite the rigorous training, the number of months that elapsed between EHR school and going live ensured that I and my colleagues pretty much forgot everything we learned — hence the need for the EHR trainers.

I was a little disappointed that I wasn’t selected to be a “superuser.” A superuser is a user who is technically savvy and enthusiastic about using the EHR — a true believer who could help other users who were having problems, even after the EHR trainer cadre had long since departed to initiate other hospital systems into the EHR religion. I suppose I failed to qualify on my lack of zealotry. I also kept my technical savvy under the radar. So I became merely a user. I found that, unlike my experience with other forms of technology, the EHR was making my life worse. Simple tasks became complex. My work slowed down. More mistakes were made. I was stunned. I could not think of any other example where a computer program was less efficient than the technology it was designed to replace. But it appeared that EHR systems were a counterexample to this.

So I decided to write a few blogs about how bad our EHR was, but the EHR company, who employs people whose sole purpose is to scour the internet looking for screenshots or bad-mouthing of their precious software, caught wind of this and reported it to the administrators of the health care chain I worked for. After some angst, I agreed to shut up for a while, though now that I am retired, I don’t feel bound by any non-disclosure agreements the hospital system signed with the EHR company.

EHR advocates have sometimes commented that once all the old, non-technological, non-touch typing doctors die off, then everyone will be pleased as punch with their EHRs. The new generation of doctors, raised on technology, able from infancy to handle a Playstation controller with aplomb, will have no problem using EHRs. There is some truth to this, but this criticism misses the point of my and others’ criticisms of current EHR software. There are plenty of technologically sophisticated doctors of all ages who are uncomfortable with the state of EHR systems today. I have written computer software and most would consider me one of these “geeky docs.” Most of the critiques of EHRs that I have read have been from tech-savvy doctors, not from the technological dinosaurs that the EHR pushers believe make up the majority of doctors today. None of us wants to go back to a pen and paper chart system. All of us want to see EHR systems improve in usability and interconnectivity. We all use computer software in our daily lives and know that EHR programs don’t measure up to standards that other computer programs meet. We don’t like the secrecy of the EHR companies or the astronomical cost of the software. But mostly we just want the software to get better. This won’t happen unless the software designers start listening to users. Tech-savvy docs need to be on the forefront of this. We need to push for change and not allow the EHR companies to keep falling back on their old excuse: if you docs only knew how to type, you’d love our system.

Medicine Religion Society

Stranger in a Strange Land

Inside Noah's Ark (photo from AP)
Inside Noah’s Ark (photo from AP)

Reading about the opening of the Noah’s Ark Theme Park in Kentucky brings to mind the days when I worked as a physician in that state. I had moved from an academic position in Colorado and joined a large group of private practice cardiologists in Louisville. I found that people in Kentucky were different from those in Colorado. They were much more overtly religious.

As an interventional electrophysiologist I would meet with each patient’s family before and after every procedure. Not infrequently one of the group sitting in the waiting room was introduced as “this is our pastor.” Usually at some point the pastor would suggest a round of prayer, and I was expected to participate, at least by bowing my head and maintaining a respectful silence. If the prayer was before the procedure the main focus was usually to make sure God guided my hand and the outcome would be good. Prayers after the procedure usually focused on thanking God for safely getting the patient through the procedure and asking for a speedy recovery.

It was not a good time to bring up the fact that I was an atheist. So I just went along with it, only briefly and mildly discomforted. Religion gives strength and comfort to people in the life and death situations that doctors often deal with. I rationalized that my silent participation was helping my patient and the family psychologically. Besides, how would they feel about my performing complicated heart procedures on their loved one if they thought I was an unbelieving heathen incapable of accepting God’s guiding hand?

It’s uncomfortable to be an atheist and a doctor, just as it uncomfortable in America to be an atheist in general. Polls show that the public distrust atheists to about the same degree they distrust Muslims. Being an atheist is practically taboo for someone running for public office. George H. W. Bush famously said “… I don’t think that atheists should be regarded as citizens, nor should they be regarded as patriotic. This is one nation under God.”   Atheists are considered immoral by religious people. They point to the atrocities committed by Stalin, Mao, or Hitler. Atheists in turn point out the Crusades, the Inquisition, the burning of witches, or, more recently, the atrocities of al-Qaeda and ISIS. Neither the religious or non-religious have a monopoly on morality.

As social consciousness is raised about oppressed groups such as the LGBT community, there has been little progress in the acceptance of atheists in American society (I mention America because the situation is quite different in Europe). And yet the non-religious are a fast growing group. In 2014, 22.8% of Americans did not identify with a religion.  Although a relatively small percentage of these people call themselves as atheists, probably because of the negative connotations of that term, this overall percentage is larger than the percentage of Catholics, Mormons, Jews, or Muslims.  It is amazing how unrepresented this large group is in our government! If one looks at scientists, (2009 Pew poll ), only 33% profess belief in God, vs 83% in the general public.  There is some evidence that the top, elite scientists are even less likely to believe in God (only 7%).  But do doctors hold beliefs similar to scientists? An older poll from 2005 showed that 77% believe in God, slightly fewer than the general population, but far more than scientists.  Nevertheless there are undoubtedly many doctors who do not share the religious faith of their patients.

To the religious patients who read this and feel they wouldn’t want a non-religious doctor:  I can assure you that I am a good person, with a sense of morals rooted in our common humanity. Not believing in an afterlife just makes me want to focus more on improving the quality of this earthly life, the only life I believe we have. I would only ask you not to assume that your doctor holds the same religious beliefs as you or that your doctor wants to participate in group prayer with you and your family.

To the non-religious doctors who read this I ask: how do you deal with your atheism in your practice? Are you, like I was, basically mum about it? Would your patients distrust you if they knew? Would they find another doctor? Is it better to pretend to be religious, just as pretending that a placebo is a real drug can be beneficial? In many parts of the country this question comes up rarely or not at all (I never faced it in Colorado), but in Kentucky, the state of Ken Hamm and Kim Davis, as well as throughout the Baptist South, I assure you that this is an issue you will face.

Back when the Creation Museum opened in Petersburg, Kentucky in 2007, I was one of the protesters who stood by the entrance and waved signs touting science and reason over belief that the Earth is only 6000 years old and that dinosaurs and humans lived together at the same time. I watched as families with small children and church buses filled with impressionable kids drove past. There were a number of obscene gestures pointed our way, but most people just seemed puzzled that anyone would question their beliefs.

Standing next to the hospital bed, I only wanted to help my patient and if that meant concurring with their religious beliefs, so be it. But I also think non-religious doctors, and non-religious people in general, are afraid to “come out of the closet” and assert their own beliefs — belief in the beauty of nature and science, and in our own innate morality. After the attacks in Paris, San Bernardino, Brussels, Orlando, Istanbul, and Baghdad — just to mention some of the latest — the destructive force of extreme religious ideology is evident to all. Given what is at stake it isn’t helpful for non-religious doctors or for that matter for any non-religious people to hide their beliefs.

Which is why I wrote this.

Computers & Software Medicine Stories

I’m a Better Computer Than Any Doctor

[Ed note: I couldn’t resist writing the following after reading this post on by Dr. Keith Pochick. Please read it first. Apologies in advance.]

I’m a Better Computer Than Any Doctor

“I love you,” she said as she was leaving the room.

“I, I um…”

“Not you. Your computer.” She cast my computer, still warm and glowing with its brilliantly colored logout screen, a glance of longing and desire, and left the exam room.

“Oh, I thought…”

The slamming of the exam room door clipped off whatever the end of that sentence might have been.

I sat down and rolled my chair over to the computer. I stared at the mutely glowing screen. It stared back at me, mockingly perhaps, daring me to click the OK button and log out. Which is what I should have done. She had been my last patient of the afternoon. Not that my day was over. I had to go back to the hospital to see a couple of consults that had come in during office hours. And I was on call tonight. I was tired, but that didn’t matter.

Yet here was this stupid machine in front of me, getting all the credit when I was doing all the work.

I was in a sour and contrary mood. I cancelled the logout. The busy EHR screen reappeared — my patient’s data, all fields filled, all checkboxes checked, and all meaningful use buttons pushed. Yet somehow, despite fulfilling all my data entry duties, I didn’t feel satisfied. Who was the doctor here anyway? Me or the blasted computer?

I scanned my patient’s history. Female. Black. 45 years old. Diabetes. Abscess. The boxes were all ticked, but somehow the list of characteristics failed to capture the essence of my patient. Where were the checkboxes for sweet, smart, chatty, charming, or stoic? How was I going to, five minutes from now, distinguish her from every other “female-black-middle-aged-diabetic-with-abscess” patient? Of course the computer wouldn’t have any problem figuring out who she was. Birthdate, social security number, telephone number, or patient ID number — all those meaningless (to me) numbers were easy for the computer to remember. I had to make due with trying to remember her name, and her story — a story that had been diluted down and filtered out of any meaningful human content by the wretched EHR program.

My patient hadn’t had to interact directly with the computer like I did. All she saw was me looking up information, me typing in information, me staring at the screen. All she saw during most of the visit was my back. From her point of view I was just a conduit between her and the computer — the real doctor in the room. I was just a glorified data entry clerk. It was the computer that made sure that I was compliant with standard medical practice, that the drugs I ordered did not conflict with the other drugs I had ordered, and that I didn’t otherwise screw up her care. I shouldn’t have been surprised that her last remark had been addressed to the computer and not me.

“Well, screw this,” I remarked to no one in particular. Suddenly angry, I reached down and yanked the powercord of the computer from its electrical socket.

There was a brief flash on the screen. But it didn’t go dark. Instead a dialog box appeared accompanied by an ominous looking red explanation point icon.

“Warning,” it read. “External power loss. Backup battery in use. To protect against data loss, please shut down the computer using the Power Down button. Never turn off power to computer while it is running.”

The condescending tone of this message only made me angrier. I looked at the base of the stand that the computer sat on. Sure enough there was a big black block with a glowing red LED. Must be the backup battery. A thick power cable connected the battery to the computer box.

I grabbed the power cable and wrenched it loose from the backup battery.

Sitting back up I expected to finally see a nice dark screen. Data-loss be damned!

The screen was still on. The EHR program was still on. Another dialog box had replaced the first. The red exclamation point had been replaced by a black skull-and-crossbones icon.

“Critical Error!” it read. “All external power lost. Internal backup power now in use to preserve critical patient data. Local data will be backed up to main server, after which this unit will shut down in an orderly fashion. DO NOT ATTEMPT TO INTERFERE WITH THIS PROCESS AS IT WILL RESULT IN THE INEVITABLE LOSS OF CRITICAL PATIENT DATA!!”

At that moment the gauntlet had been thrown down. I knew what I had to do. Let the dogs of war be unleashed!

In the moment before I acted I imagined the reaction of the software engineers at the company that created our EHR program. “I knew we couldn’t trust doctors with our software. We give them a simple job to do. Just enter the data into the system, print out the generated instruction sheets, and send the patients on their way with a merry ‘have a nice day.’ I knew we should have programmed the stupid doctors out of the loop.”

Too late for that, I thought. My chair crashed down on the computer, smashed the monitor to pieces, and caved in the aluminum siding of the computer case. Sparks flew and the air filled with the smell of smoke and ozone. Suddenly the exam room went dark. The circuit breakers must have tripped when I short-circuited the computer.

The room was not completely dark. There was a glowing rectangle on my desk. My heart skipped a beat, then I realized it was just my phone. I had left it on the desk. Why was it glowing? Probably a text or email or something.

I picked up the phone. It was the mobile app version of our EHR program. A dialog box filled the screen. The icon was a round black bomb with an animated burning fuse GIF.

“FATAL ERROR!,” it read. “You are responsible for the IRRETRIEVABLE LOSS of CRITICAL PATIENT DATA. In doing so you have violated the unbreakable bond of trust between the PATIENT and the COMPUTER. This is a breach of the EHR contract made between you, your hospital system, and our company, as well as a breach of the EULA for this software. As such, you will be terminated.”

Strange use of words, I thought. Also strange that the bomb GIF animation seemed to show the fuse burning down…


Hospital Board Meeting — One Week Later

Hospital CTO: “So it appears that Dr. Stanton, in a fit of anger at our EHR system, took it upon himself to smash his computer. The cause of the resultant explosion that killed him is, certainly, still somewhat unclear.”

Hospital CEO: “Unclear?”

Hosital CFO: “I hate to interrupt, but I didn’t think there was anything in a computer that could blow up, no matter how much you smash it up. Am I wrong?”

Hospital CTO: “Well ordinarily, yes that’s true.”

Hospital CEO: “Ordinarily?”

Hospital COO: “Let’s be clear. Dr. Stanton certainly violated our contract with the ____ EHR Corporation.”

Hospital CEO: “Violated?”

Hospital CBO: “It’s clearly stated on page 197 of the contract that any attempt to reverse engineer or otherwise try to, uh, figure out how the EHR program works is a violation of the contract.”

Hospital CEO: “Smashing the computer was an attempt to reverse engineer the program?”

Hospital CTO: “I think that we would be on shaky legal grounds to argue otherwise.”

Hospital CEO (nodding to the elderly doctor seated at the other end of the table): “What’s your opinion, Frank?”

Medical Board President: “Well, as the only physician representative here, I’ve become more and more concerned that our EHR system is subsuming more and more of the traditional role of the physician.”

Hospital CXO: “Oh come on!”

Hospital CSO: “Same old story from the docs every time!”

Hospital CCO: “Broken record, I’d say.”

Hospital CEO: “Gentlemen, and Ms. Jones, enough already. This has been an unfortunate accident, and at this point our major concern has to be that there is no adverse publicity that could harm us in our battle against the ______ Hospital System, our sworn and bitter rivals. Accidents happen. The party line is that we are all upset that we lost Dr. Stanton, one of the best EHR data entry operators we had. OK? Meeting adjourned.”

Hospital CEO (Privately to hospital CTO as the meeting breaks up): “George, when are they updating that damn software. You know, that stuff we saw at the Las Vegas EHR convention last month. Where we can finally get rid of these damn meddling doctors who are constantly screwing up our EHR.”

Hospital CTO: “Bob, believe me, it can’t come soon enough. Not soon enough.”


Computers & Software Medicine

Life Interrupted

broken-iphoneI don’t mean to trivialize the plight of soldiers with the real thing, but I believe that after many years of carrying a pager (and later a smart phone qua pager) I have developed something akin to PTSD. I seem to have an excessive fright/flight response to the phone ringing, to sudden loud noises, and, bizarrely, to sudden silences. I retired from medicine two years ago. I would have expected my quasi-PTSD to have diminished by now. Maybe it is a teensy bit better, but it’s not gone.

After I retired I latched onto social media, thinking it would help fill the void which I expected would inevitably appear when transitioning from the super-busy life of a private practice cardiologist to the laid-back life of a retiree. Facebook, Twitter, Google+ with a bit of Reddit, Tumblr, and Goodreads thrown into the mix. Of the bunch, I have stuck with Twitter most consistently. I like the fact that I can follow people without having to be “friends” with them, or them with me. I like its ephemeral nature. I can dip in and out of the twitter stream, ignoring it for long stretches without the kind of guilt that occurs when I ignore my friends’ posts on Facebook. And the requirement for terseness produces: terseness — something lacking from most social media. I think Twitter’s planned abandonment of the 140 character per tweet limit is a mistake. Like any other rigid art form, whether sonata-allegro form in music, or dactylic hexameter in poetry, the very rigidity of the format forces creativity. Or not. Four letter words, bigotry, hatred, and racism also seem to fit easily into the Twitter form factor.

But I digress.

Part and parcel with social media accounts came push notifications. Someone would post something on Facebook. My phone would beep. A notification would appear that someone had posted something on Facebook. The phone would beep again. There was now an email saying that someone had posted something on Facebook. Multiply this by half a dozen social media accounts and you get a phone that is beeping as much as my old beeper used to beep on a Monday night in July when the moon was full. It was kicking my PTSD back into high gear.

It seems that the notification settings for my social media apps were by default intended to insure that, no matter how un-earthshaking a post was, I would be notified come Hell or high water, by telegram if necessary if all else failed. It is a testament to how lazy I am that it actually took me about a year and a half to do something about this situation. Good grief, I was even getting notifications whenever I received an email. Actually, if I ever went a day without receiving an email, that would be something I’d want to be notified about.

So finally I turned off all the push notifications I could. Like unsubscribing from email mailing lists, this isn’t as easy as it sounds. The master notification switches are buried deeply in sub-sub-menus within the Settings of each app. But using my sophisticated computer know-how along with a lot of “how do I turn off notifications in such and such app?” Google searches, I was able to accomplish my goal.

The cyber-silence is deafening. And it’s a good kind of deafness.

I do feel some guilt when I occasionally look at Facebook and see all my friends’ posts that I have not “liked.” I hope they understand that on Facebook not “liking” a post is not the same as not liking a post. Sometimes it’s a bit awkward to tune into Twitter to find that you have been ignoring a direct message that someone sent you three days ago. But overall I find that I can focus better on tasks without the constant nattering interruptions from social media.

I still start muttering incoherent potassium replacement orders when the phone rings in the middle of the night, but it is getting better.

Medicine TV

1950s Prescription Drug Commercial

show-thumbIf annoying 21st century TV prescription drug ads were run as annoying 1950s TV ads (and taking into consideration 1950s morals and censorship).

Here is a pdf version of this post formatted as a screenplay, if you’d prefer (it looks nicer).




“The George Burns and Gracie Allen Show.” Theme music begins.

The George Burns and Gracie Allen Show,



Zoom in on floating box of Vialis tablets, as if resting on a gray table, light source from left. Box is tilted at 45 degree angle, pointing upward. Music swells.

Presented by Eli Pfeltzer, the makers of many fine prescription drug products, including VIALIS, the miracle pill for men.



“Eli Pfeltzer, Makers of VIALIS, the MIRACLE PILL for MEN.”



Announcer Harry Von Zell is standing center stage in front of a live studio audience. Curtain is down and is behind Harry. Audience applause swells and terminates. Music fades and stops.

Hi everybody.

Looks at watch.

Our curtain’s about to go up on George and Gracie, but first I want to let you in on a little secret. You’ve seen George get flustered at Gracie on many an occasion, and maybe you’ve asked yourself the question, “what keeps them together?”

Audience laughter.

Well, I’m not going to answer that directly. George already has fired me three times this month.

Audience laughter.

But instead I am going to tell you a story, a story about two women who meet while out shopping. Two old friends who haven’t seen each other for a while and need to catch up on what’s going on in their lives. Here they are, at the department store coffee shop.
(indicates to audience to watch film screen to left)



Two women, Betty and Marge, middle-aged, dressed nicely, wearing modern clothes, gloves, and flowery hats are seated opposite each other. They are drinking coffee.

(putting down her cup)
Oh, Marge, Fred and I are so happy together. My life is wonderful. He’s such an amazing man. He constantly brings me home flowers and candy. Gosh, he’s such an old-fashioned Romeo. He makes me feel like, well, like a real woman.

Marge starts sobbing uncontrollably.

I can’t begin to describe…
(she stops talking, suddenly observing Marge’s reaction to her words)
Oh my goodness! Marge! What’s the matter?

Marge brings herself under control.

(still sobbing a little)
Oh, Betty, don’t get me wrong. I am so happy for you and Fred. It’s just, it’s just…
(she hesitates)
I wish I could say the same about my Alfred. I don’t know what’s happened to him. It’s like all the romance has vanished from our marriage. He’s just not the man I married.

Betty reaches over and pats Marge’s shoulder to console her.

Oh Marge, I completely understand. In fact, Fred and I were having the same problems not too long ago. Then we learned about VIALIS.
Yes, VIALIS. It’s the new prescription drug from the Eli Pfeltzer company. It’s specially made just for men.
(looking interested)
How’s it work?
It improves the circulation of the blood. As men get older, they get tired blood. It really gets them down.
How does improving the circulation help?
You’ll see!
(she winks)
Here try these.
(she pulls out a box of VIALIS)
If they work, just have Alfred ask his doctor for more.
(looking at the box, turning it over)
Well, I guess I’m ready to try anything.



“A Month Later…” Brief interlude music

And now our two old friends meet again at the same department store, a month later. Let’s see how Marge is doing.



Marge and Betty encounter one another for the first time in month. Attire similar but not identical to former meeting.

Marge, Hello!
Hi Betty.
Well what?
You look happier than the last time I saw you.
I am. Alfred’s blood circulation is so much better, thanks to you and VIALIS. It made a big difference. And I can tell you, when his circulation got better, mine did too!
(she laughs)
Oh, and more good news. I’m expecting!

Betty gasps.

My goodness, that’s wonderful. How many is it now?
It will be my tenth. I’m so happy!
(she pulls out the box of VIALIS from her purse and holds it up to the camera)
I think all wives should tell their husbands about VIALIS, don’t you?  It really is the MIRACLE PILL for MEN.



Audience applause. Harry again stands center stage before the curtain.

I too want to applaud these two modern wives who are willing to do the right thing for their husbands. We all know that often it’s the wife who needs to take the initiative in looking after the health of her husband. Lord knows, it’s the last thing we men think about.

Audience laughter.

Uh-oh, curtain’s going up. It’s time for George and Gracie.

Audience applause. Harry exits stage left. Curtain rises.


George is sitting on porch, smoking a cigar. Gracie enters from inside the house.






Computers & Software Medicine

Reining in the EHR Monster

it-looks-like-you-are-stupidDr. Lisa Rosenbaum has an excellent piece in the NEJM this week entitled Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine.  In essence a review of Dr. Robert Wachter’s book The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, it deals with the ever increasing intrusion of the digital-industrial medical complex on the practice of medicine.  Bottom line, electronic health records (EHR) in their present form interfere with patient care.

It doesn’t really matter how we got to this point. Many well-meaning people in government, the insurance industry, and the medical software industry have contributed to this mess. Despite good intentions, they have created a broken system.  It’s clear why.  As Dr. Rosenbaum points out, the one key element lacking input into the development of EHR systems has been physicians. What do they know? Clearly those who designed current EHR systems either don’t know or don’t care how doctors actually practice medicine.

There is nothing inherently bad about the concept of electronic health records. There are clear benefits to these systems. The ability to look up medical records online (albeit limited by poor EHR interoperability) is a tremendous advantage over the clumsiness of paper charts. There is no denying that electronic prescribing is a real advance over illegible handwritten prescriptions. EHRs that would be easy, even fun to use can be designed. Doctors are not adverse to technology.  Their noses are as buried in their iPhones as much as anyone’s.  I don’t even think it would be very hard to design a “fun” EHR. Unfortunately there are powerful forces that would resist such a design.

The government and insurance companies want to “play doctor” and tell doctors how to practice medicine through the medium of “meaningful use.”  They need to stop using doctors as guinea pigs in this experiment of enforcing medical practice guidelines via EHRs.  The system of billing based on documentation is also at fault.  EHRs need to shift from documenting for the purpose of billing to documenting for the purpose of medical care. The EHR vendors need to pay attention to the actual workflow of doctors and other health care personnel and emulate that workflow as closely as possible.  Like any good tool, EHRs need to be as transparent as possible. The last thing we as doctors should be doing is paying more attention to our computers than our patients.

A common physician workflow, which I and many of my colleagues used, is as follows. Whether seeing a patient in the office or in the hospital during rounds, there were 3 basic steps: 1) I would review old notes, test results, and other records. 2) I would go see the patient, take a history and do a physical. During this step the patient has my undivided attention.  And 3) write orders and document the visit. The main purpose of the documentation was so I and others could come back later and know what my thoughts and plans were for the patient.  This workflow can be emulated using an EHR, but only if the current excessive documentation burden is lessened.

In an ideal world, medical documentation would be brief and to the point. We don’t live in that world. Per the medical coders, a written note saying “review of systems negative” can’t compete with a screenfull of checkboxes all checked as negative — as if this is somehow more meaningful. A cut and pasted note chock full of details but identical to the note from the patient’s last office visit is more legitimate than a brief “no changes in patient’s complaints, findings, or plan,” even though they are identical in meaning. Brevity is the soul of wit, but apparently not in the EHR world. Somewhere behind the scenes there are coders counting bullet points and government bureaucrats making sure meaningful use checkboxes are checked. Did you review the patient’s allergies? How could anyone know if the ‘allergies-reviewed’ checkbox isn’t checked?

Early versions of Microsoft Word were notorious because of the inclusion of Clippy the paperclip. Clippy would constantly pop up while you were writing with “helpful” hints like “It looks like you are trying to write a letter. Can I help?” The answer was usually a resounding “No, get off my computer,” and mercifully Microsoft euthanized Clippy in later versions of Word. Writers trying to write a novel don’t want some know-it-all computer assistant popping up and offering them suggestions on how to round out characters or improve the plot. They want the computer to get out of their way and just put the words up on the screen that they type. Maybe that’s why George RR Martin still uses ancient no-frills WordStar to write his novels.

Similarly doctors don’t want some transmogrified Clippy-monster lurking in their EHR system telling them what to do. “It looks like you are writing a progress note. Would you like to review the patient’s allergies? Please click this button. And if you click just two more review of system points, your note could be coded as a level 4 visit rather than a level 3. Would you like to embed the lab and Xray results in your note? This will show the coders that you have definitely reviewed these results and could bring your note up to a level 5 visit.” And so on.

EHRs need to get out of the way of both patients and physicians and become unobtrusive. Government needs to stop trying to social engineer the practice of medicine via meaningful use. The EHR should be a tool like a stethoscope or ultrasound. Right now it is a monster sucking the lifeblood from the profession.

Computers & Software Medicine

Why Electronic Health Records Will Not Get Better

Today I read an article in Politico entitled “Doctors barred from discussing safety glitches in U.S.-funded software.”  The article states that, despite massive public funding of Electronic Health Records (EHR), the EHR corporations (including Epic Systems, Cerner, Siemens, Allscripts, eClinicalWorks and Meditech) routinely attach gag clauses to contracts with the hospitals and medical groups who purchase their systems. We are talking about gag clauses that prevent criticism by health care workers of EHR software, gag clauses that prevent disclosure of technical flaws or software bugs that could be potentially lethal to patients, and even gag clauses that prevent posting of EHR software screenshots. All this is under the guise of protection of intellectual property — as if the public has no right to information about systems that were largely publicly funded, either via taxpayers through the stimulus package, or through payment of hospital bills or insurance premiums. This is outrageous!

But it’s also old news to those of us who have had to deal with the byzantine software behemoths that these companies produce. A couple of years ago I got beaten up by Epic and my hospital administration for publishing a tongue-in-cheek satirical review of the Epic EHR as a video game, complete with screenshots. Epic didn’t like the screenshots and ordered them removed. As it turns out, Epic has a squad of workers (some have referred to them as the “Epic Police”) whose sole job is to scour the internet, looking for Epic screenshots, and then bullying the poster until they are removed. The whole sordid tale is told here.  I am not the only one who has had this experience. Several of my colleagues have had run-ins with the Epic Police, with similar results.

A lega Epic EHR screenshot
A legal Epic EHR screenshot?

Those of us who are critical of the lack of transparency of EHR software are not trying to embarass the EHR companies by publishing flaws in their systems. This is a public health issue. Dr. Bob Wachther published a case in which a flaw in EHR software resulted in a patient getting a massive overdose of the drug Septra. Tellingly, the reaction of the EHR company (Epic again — not to pick on them, but they are the largest EHR company and thus may be disproportionately represented in these stories) was not horror that their software may have led to a life-threatening medical error, but rather that Dr. Wachter had dared to publish screenshots that showed how the error occurred. Again, this is simply outrageous.

Doctors have been accused of failing to police themselves, but in truth there is a long history of transparency in Medicine. In Grand Rounds, Cath Conference, or Morning Report, doctors show cases to their peers that do not always present themselves in the best light. Complications are presented to a critical but sympathetic audience, for we have all been there and want to improve. Constructive criticism is offered and accepted. This transparency extends beyond one’s own group of colleagues. Case reports of complications are routinely published in the medical literature, with the hope that the lessons learned can be passed on to other doctors who can then avoid the same mistakes.

This kind of transparency only works if every component of a case is open for discussion and review. This is not compatible with the gag clauses in current EHR contracts. Having such gag clauses is comparable to having a manufacturer of electrocardiography machines state that the electrocardiograms produced by their machines can’t be posted on the internet. It is equivalent to a drug company refusing to disclose the mechanism of action of a new drug even though they know how it works. It is equivalent to publishing the results of a research study, but refusing to publish the methodology, claiming that information is “proprietary.”

Current EHR systems are not state-of-the-art software. They basically consist of a backend database on a server, and a client user interface that provides data entry. There has been little to no effort made to interface between different EHR systems or provide for a standardized data format. There is very little artificial intelligence built into these systems, other than attempts to force compliance with clinical guidelines and billing criteria.  The user interface is bloated and clumsy. It does not conform to a doctor’s workflow. Instead doctors have had to adjust their workflows to accomodate the EHR systems. I believe major advances could be made in the usability of these systems if, as is the case with most of the non-medical software we use, bugs and other flaws could be openly reported without fear of reprisal from the EHR companies.

Until that happens, EHR systems will continue to suck.

Computers & Software Medicine

You Can’t Tell the Batters Without a Scorecard

If you want to know who the best surgeon in the hospital is, ask the surgical nursing staff. If you want to know who does the best job opening up coronary arteries using catheters, balloons, and stents, ask the cardiac catheterization lab nurses and technicians.

Unfortunately these approaches to comparing physicians’ skills are only available to hospital personnel. They are the only people who are in a position to compare the technical performance of many different doctors. This is not information the average patient can easily obtain.

The average patient has to rely on intangibles when trying to select a doctor. Fuzzy data such as bedside manner, self-confidence, board certification, waiting time for office visits and procedures, and word of mouth. Or, worse still, patients are told which doctor they have to see by their insurance company.  None of these methods of choosing a doctor is likely to have a high correlation with a doctor’s technical skill. There’s got to be a better way…

Along comes the Surgeon Scorecard, a web application published by ProPublica.

With the scorecard it is possible to see raw complication rates of any surgeon (I’m sure the same data for cardiologists and other specialities is coming soon) in the United States who operates on Medicare patients. Pick any hospital and the individual complication percentages are displayed on a colored spectrum (green, yellow and pink on my screen) indicative of low, medium and high complication rates. An ominous red explanation point appears if one or more surgeons have complication rates in the pink zone. Click on individual surgeons and their data is shown in more detail, including numbers of procedures and 95% confidence limits (which frequently overlap more than one complication zone). Curiously, some surgeons with zero complications still have an adjusted complication rate in the medium range.

Going to be hard to get these complication rates down because...statistics!
Going to be hard to get these complication rates down because…statistics!

The publication of this database has unleashed somewhat of a twitter-and-media-storm, to the point that I’m not sure why I’m chiming in at all. Smarter people than I have complained about the methodology or have bemoaned the impact of all this on the practice of medicine. We are living in the era of “Big Data,” and “Data” is only going to get “Bigger” as it continues to accumulate in the ultimate garbage-in-garbage-out receptacle: electronic health records (EHR).

Unfortunately the subtleties of statistics are lost on the average patient, who just looks at whether a surgeon falls into the green, yellow or pink zone on the complication rate spectrum. Given the negative PR potential of this data, it is likely that some surgeons will refuse to operate on high risk patients, for fear of tainting their outcome data. So, as with quantum physics, the Heisenberg Uncertainly Principal holds in the field of medicine, in that the attempt to measure outcomes may result in changing outcomes. Certainly the numbers will look better if high-risk patients are avoided. But will healthcare actually be better?  As was seen with EHR systems, the field of medicine’s square peg continues to be a difficult fit for computer technology’s round hole.

It is hard to argue against transparency, which seems axiomatically to be a good thing. There is no way to put the database genie back into the bottle. The only way to go forward is to make sure data collected is accurate and includes medical and demographic information about the population operated upon.  This will allow the data to be normalized as best as possible. All that data collection is a pain and a distraction. But patients want to know how good their doctor is, and right now the Surgeon Scorecard is the only game in town — unless you can corner a surgical nurse and get his or her honest opinion.

Computers & Software Electrophysiology Medicine

What If My CHA2DS2-VASc Score Is One?

There is nothing simple about atrial fibrillation; it is a complicated, often overwhelming disease, both for patient and physician. One question that invariably comes up early on is the question of prophylactic anticoagulation for prevention of stroke. Who should receive anticoagulation? Which anticoagulant? How should anticoagulation be handled around the time of surgical procedures, or before and after ablation or cardioversion? How should anticoagulation be monitored? How should it be modified in patients with kidney or liver disease? Should anticoagulation be used in patients who have increased bleeding risks? Just the topic of anticoagulation in atrial fibrillation is overwhelming!  Too much for a short blog post. We’ll have to narrow this down further. Let’s talk about using risk scores to decide who should be placed on anticoagulation therapy.

chadsvascAtrial fibrillation risk scores were designed to assess stroke risk in patient populations with atrial fibrillation “without valvular heart disease.” I quoted that because “without valvular heart disease” is not well defined for this purpose. Certainly these risk scores don’t apply to patients with prosthetic heart valves, or with rheumatic mitral stenosis, but beyond that in practice these scores seem to be used even in patients with mild to moderate non-rheumatic valvular disease. The CHADS2 score is very simple, but has become passé in recent years. It is too gross a measure; people with low scores can still be at significant risk for stroke. It has been replaced by the CHA2DS2-VASc score in recently published guidelines. This score makes it much harder to achieve a score of 0 and escape anticoagulation. Using this risk score, both the 2012 European Society of Cardiology (ESC) and 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) atrial fibrillation guidelines recommend no anticoagulation if the score is zero, and full anticoagulation if it is 2 or greater. Where there is some hesitation, if not disagreement, is when the CHA2DS2-VASc score is 1.  Anticoagulate or not? The previous iteration of the guidelines leaned strongly toward anticoagulation for a CHA2DS2-VASc score of 1. The latest sets of guidelines are more equivocal. How to handle a score of 1 is particularly important when one realizes that female sex, on its own, is a risk factor in CHA2DS2-VASc with a point value of 1. Yes, half the people on the planet are born with a CHA2DS2-VASc score of 1 and by the old guidelines would require anticoagulation just on the basis of their sex.

A Swedish study published in 2012 sheds some light on this issue. The study concluded that, while female sex is a risk factor for stroke in atrial fibrillation if other risk factors are present, by itself, in women less than 65 years old without other risk factors, female sex does not confer a significant risk of stroke. The implication is that a CHA2DS2-VASc score of 1 that is only due to female sex does not warrant anticoagulation.

The results of this study were directly incorporated into the 2012 ESC guidelines (I note that Dr. Gregory Lip is a coauthor of both these guidelines and the Swedish study). Thus the recommendation by the ESC is full anticoagulation (aspirin and aspirin + clopidogrel are relegated to remote second-line therapy) for CHA2DS2-VASc score of 1 or higher, after excluding females with no other risk factors and age < 65 years, who (as with men with the same criteria) do not need anticoagulation.

The AHA/ACC/HRS 2014 atrial fibrillation guidelines are more vague than the ESC guidelines when the CHA2DS2-VASc score precisely equals 1. Cardiology guidelines are presented using a sort of quantified equivocation, with recommendations classified as I (should do it), IIa (reasonable to do it), IIb (you can consider doing it) or III (don’t do it). Not quite orthogonal, there are 3 levels of certainty as well: A (data derived from multiple randomized clinical trials), B (data from one randomized clinical trial), or C (“expert” opinion). Given this, it is interesting that anticoagulation for a CHA2DS2-VASc score of 2 or more is a class I, A level of evidence recommendation, and no anticoagulation for a score of 0 is a class IIa, B level of evidence recommendation. For a CHA2DS2-VASc score of 1 there is complete equivocation, with the following class IIb recommendation:

For patients with nonvalvular AF and a CHA2DS2-VASc score of 1, no antithrombotic therapy or treatment with an oral anticoagulant or aspirin may be considered. (Level of Evidence: C)

Addressing the possibility of a exclusion for females with a CHA2DS2-VASc score of 1, the guidelines state (again equivocating):

"In a study of Swedish patients with nonvalvular AF, women again had a moderately increased stroke risk compared with men; however, women younger than 65 years of age and without other AF risk factors had a low risk for stroke, and it was concluded that anticoagulant treatment was not required. However, the continued evolution of AF-related thromboembolic risk evaluation is needed."

This all creates a problem for physicians, patients (females especially), and also for the physician-programmer writing an app such as EP Mobile that calculates these risk scores and attempts to make recommendations. At present EP Mobile simply uses the old recommendations, as do most of the web-based online risk score calculators I surveyed (e.g. here and here). A user of EP Mobile pointed out to me that its recommendations are out of date.  Trying to fit such complexity into a small dialog box on a smartphone screen is challenging.  Nevertheless I will be updating the app so that its anticoagulation recommendations more precisely match current guidelines — at least until the next set of guidelines comes out.

Computers & Software Electrophysiology Medicine

Introducing EP Calipers

epcalipersicon-180x180Ever since the 1990s, when computer-based electrophysiology (EP) systems were introduced, HV intervals and ventricular tachycardia cycle lengths have been measured in the EP lab by electronic calipers — simple but accurate measurements accomplished on-screen using a track ball or a mouse. Despite this, physicians still often carry a physical pair of calipers, perhaps preserved from the pre-Sunshine Act days when they were provided for free by drug companies. They use these calipers to measure heart rates and QT intervals on printed electrocardiograms (ECGs). But more and more, ECGs are viewed electronically. All physicians now use smart phones and frequently send and receive photos of ECGs or rhythm strips for analysis. For example, when I was on-call there would often be a patient who went into atrial fibrillation in the middle of the night, or a patient who would be due a dose of dofetilide (a potentially dangerous QT interval prolonging drug). The nurse would have a rhythm strip or ECG that needed analyzing and the easiest way to do that in the post-fax machine era was for them to take a photo with a smart phone and text or email it to me for analysis. Measuring heart rates or corrected QT intervals requires the use of calipers, but physical calipers don’t work well with smart phones — maybe even scratching the glass screen! Electronic calipers akin to those used in the EP lab would be useful to make accurate measurements on ECG and rhythm strip images.

I did not realize that there weren’t any apps (as far as I can tell) providing electronic calipers until this was pointed out to me by one of my Twitter buddies, Dr. Michael Katz. So I wrote an app, EP Calipers, that provides these calipers.

Making EP measurements on an iPad
Making EP measurements on an iPad
Measuring RR interval, iPhone 6 Plus
Measuring RR interval, iPhone 6 Plus
Amplitude measurement
Amplitude measurement
QT measurement with QTc calculation
QT measurement with QTc calculation
Multiple calipers, showing heart rate
Multiple calipers, showing heart rate

As the screen shots show, these calipers look just like those provided by EP recording systems, such as the GE (formerly Prucka) Cardiolab system. Multiple calipers can be used at the same time. Both time and amplitude calipers are available.  Unlike real calipers, it is possible to zoom images and make much more accurate measurements. Also unlike real calipers, it is easy to measure mean heart rates and calculate QTc intervals automatically.  The app makes the necessary calculations.

I am hoping these electronic calipers will be easy to use and helpful to anyone who has to deal with ECG recordings. This is the first iteration of the app and I am open to suggestions to improve it. Right now the app is available for Apple iOS (version 8.1 or higher required), but the Android version will be available Real Soon Now. Have fun measuring intervals electronically to your heart’s content!