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AMIA17 – There’s Gold in Them EHRs!

Posted on November 13, 2017 I Written By

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

If even 10% of the research presented at the 2017 American Medical Informatics Association conference (AMIA17) is adopted by mainstream healthcare, the impact on costs, quality and patient outcomes will be astounding. Real-time analysis of EHR data to determine the unique risk profile of each patient, customized remote monitoring based on patient + disease profiles, electronic progress notes using voice recognition and secondary uses of patient electronic records were all discussed at AMIA17.

Attending AMIA17 was an experience like no other. I understood less than half of the information being presented and I loved it. It felt like I was back in university – which is the only other time I have been around so many people with advanced degrees. By the time I left AMIA17, I found myself wishing I had paid more attention during my STATS302 classes.

It was especially interesting to be at AMIA17 right after attending the 3-day CHIME17 event for Hospital CIOs. CHIME17 was all about optimizing investments made in HealthIT over the past several years, especially EHRs (see this post for more details). AMIA17 was very much an expansion on the CHIME17 theme. AMIA17 was all about leveraging and getting value from the data collected by HealthIT systems over the past several years.

A prime example of this was the work presented by Michael Rothman, Ph.D of Pera Health. Rothman created a way to analyze key vital signs RELATIVE to a patient’s unique starting condition to determine whether they are in danger. Dubbed the Rothman Index, this algorithm presents clinicians and caregivers with more accurate alarms and notifications. With all the devices and systems in hospitals today, alarm fatigue is a very real and potentially deadly situation.

Missed ventilator alarms was #3 on ECRI Institute’s 2017 Top 10 Health Technology Hazards. It was #2 on the 2016 Top 10 list. According to ECRI: “Failure to recognize and respond to an actionable clinical alarm condition in a timely manner can result in serious patient injury or death”. The challenge is not the response but rather how to determine which alarms are informational and which are truly an indicator of a clinical condition that needs attention.

Comments from RNs in adverse-event reports shared in a 2016 presentation to the Association for the Advancement of Medical Instrumentation (AAMI) sums up this challenge nicely:

“Alarm fatigue is leading to significant incidents because there are so many nuisance alarms and no one even looks up when a high-priority alarm sounds. Failure to rescue should be a never event but it isn’t.”

“Too many nuisance alarms, too many patients inappropriately monitored. Continuous pulse oximetry is way overused and accounts for most of the alarms. Having everyone’s phone ring to one patient’s alarm makes you not respond to them most of the time.”

This is exactly what Rothman is trying to address with his work. Instead of using a traditional absolute-value approach to setting alarms – which are based on the mythical “average patient” – Rothman’s method uses the patient’s actual data to determine their unique baseline and sets alarms relative to that. According to Rothman, this could eliminate as much as 80% of the unnecessary alarms in hospitals.

Other notable presentations at AMIA17 included:

  • MedStartr Pitch IT winner, FHIR HIEDrant, on how to mine and aggregate clinically relevant data from HIEs and present it to clinicians within their EHRs
  • FHIR guru Joshua C Mandel’s presentation on the latest news regarding CDS Hooks and the amazing Sync-for-Science EHR data sharing for research initiative
  • Tianxi Cai of Harvard School of Public Health sharing her research on how EHR data can be used to determine the efficacy of treatments on an individual patient
  • Eric Dishman’s keynote about the open and collaborative approach to research he is championing within the NIH
  • Carol Friedman’s pioneering work in Natural Language Processing (NLP). Not only did she overcome being a woman scientist but also applying NLP to healthcare something her contemporaries viewed as a complete waste of time

The most impressive thing about AMIA17? The number of students attending the event – from high schoolers to undergraduates to PhD candidates. There were hundreds of them at the event. It was very encouraging to see so many young bright minds using their big brains to improve healthcare.

I left AMIA17 excited about the future of HealthIT.

CPOE Alerts Still Vex Doctors

Posted on April 20, 2016 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

A new study by Castlight Health has found that while nearly all hospitals have implemented CPOE systems, those systems are far from perfect. And that may be because too many clinicians find system alerts to be a distracting annoyance.

The research, based on an analysis of data collected by The Leapfrog Group, found that 96% of hospitals reported use of a CPOE system, up from 33% in 2010 in a scant 2% in 2001.  This data is drawn from the 2015 Leapfrog Hospital Survey of 1,750 U.S. hospitals.

But while the high adoption rate might be good news, it comes with bad news as well. The Castlight analysis found that even where hospitals had CPOE systems in place, 39% of possibly harmful drug orders and 13% of potentially fatal orders weren’t flagged by the system in place.

The most common errors that didn’t get flagged included when clinicians prescribed the wrong meds for the patient’s condition, or the wrong dose or meds entirely inappropriate for kidney function, and the failure to display a reminder to test drug levels after issuing medication.

These errors are occurring despite the fact that many of the hospitals studied by Leapfrog (64%) met its CPOE standard. To do so, the hospitals had to alert physicians about a minimum of 50% of common, serious prescribing errors. Also, physicians had to order at least 75% of inpatient medication orders through a CPOE system.

So if the CPOE system is being used actively, and performing as it should in most cases, why would nearly 40 percent of potentially harmful drug errors slip by? The answer may be that fairly or not, CPOE alerting is still seen as a hindrance rather than a help by many physicians.

While I don’t have hard statistical evidence to this effect, the anecdotes doctors share suggest that some click through alerts as quickly as possible. One physician blogger shared that he was quite frustrated by the alert generated when he wanted to prescribe 81mg baby aspirin tablets, which patients can buy over the counter. I understand his frustration (and even what seems like wounded pride).  And if it took several clicks to dismiss the related prompts, I’m sure it was indeed annoying.

On the other hand, as my colleague John Lynn rightfully notes, doctors aren’t going to blog or tweet about the time the CPOE system alert saved them from making a major prescribing error. So there is a bias to comments and blog postings since they only cover the negative side of CPOE and not the positive side. Perhaps the doctors who are working with these alerts successfully are simply going about their business and feel no need to vent. (Please note: I’m not suggesting that those who do vent are out of line in some way.)

Still, it seems quite clear that there’s considerable work to do in improving the workflow around physician alerting. If hospitals with CPOE in place are still seeing this level of potentially harmful or fatal prescribing, after many years to adapt to alerts, they need to do more to accommodate physicians.

P.S. They might want to start with a look at how Montefiore Medical Center succeeded with its CPOE rollout.

EMR Data Deluge Means Missed Test Results

Posted on March 8, 2013 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

In theory, the rich trove of information captured by EMRs supports patient care. But in practice, when the data gets overwhelming it can  have the opposite effect, according to a new study of primary care physicians within the VA system.

A group of Houston researchers, including the VA Health Services Research and Development Center of Excellence, surveyed almost 2,600 VA PCPs between June 2010 through November 2010, asking about their experience witih EMR-based alerts.

According to a report in Modern Healthcare, almost 30 percent of PCPs said they had missed notification of test results which then lead to care delays. (These results were presented in a research letter in the AMA journal JAMA Internal Medicine.)

Under the circumstances, it’s hardly surprising that doctors would sometimes lose track of EMR alerts. Respondents in the Houston study reported that they received a median of 63 alerts a day (no, that’s not a typo). Almost 87 percent of the PCPs surveyed thought that was an excessive level.

Aside from the sheer volume alerts, other reasons PCPs felt they missed test results included poor EMR usability and gaps in electronic handoffs of a patient’s record to another provider, Modern Healthcare reports.

The researchers behind the study argue that it’s time to adapt EMRs to allow for the safe handling of test result follow-up in EMRs.

I’d argue that this, for once, can’t be laid strictly on the doorstep of the EMR vendors.  Alarm fatigue of all kinds comes up as a major IT health risk over and over again when researchers take on the subject.  So even if EMRs had embedded a way to track and highlight abnormal test results intelligently, it won’t do much to lower the distraction level in hospitals generally.

This study is just one more alarm of its own, warning  us that even the best-rested, most-focused PCP is only human and can only adapt to so many interruptions.  Lowering alarm overload in hospitals generally, be it within EMRs or outside, clearly continues to be a critical issue for hospital IT leaders to consider.