Last month I posted the testimony I submitted to the Adoption/Certification Workgroup of the Health IT Policy Committee. (I urge interested parties to review the links to other resources in that post.) Today Paul Egerman, chair of that team, circulated a preliminary draft of recommendations from that meeting. Here is my response tonight, edited a bit for clarity.
My original testimony urged a policy of letting patients see their records essentially on demand, not within 30-60 days as currently allowed by HIPAA. To encourage that, I also recommend that we mandate amnesty for errors that are found in the record. I believe no other path can lead rapidly to the goal I think we should all share: to produce better care for patients in hospitals today.
Paul (and all),
Above all, I urge that we be pragmatic. We have a chance to make rules that will, or may not, make a difference in reality. In that spirit:
- Reinforcing today’s other mails, I think it’s vital to underscore what Dr. Koppel’s webcast [RealPlayer video] illustrated: all the potential hazards you listed, and especially the UI and arbitrary hard-coded workflow rules, can get in the way of data quality.
- To me it was sufficiently scary to realize that if a system was programmed to require 40mg of something, it cannot cope with two 20mg tablets.
- To patients in hospitals for the next several years, it does no good to rant about this and demand change. As my mentor said, what works is to manage it thoughtfully.
- Regarding implementation & training deficiencies, I emphasize again that regardless of cause, what matters to patients is the gap: being aware of it and doing everything we can to deal with it. Ranting won’t solve it.
- Regarding 5, “patients can find errors” – I want to be careful not to sound like patients are proofreaders for physicians. It might be clearer as “patients can often spot errors” or some such.
- As I said earlier, we cannot absolutely prevent errors, but we can certainly minimize their impact.
- Thanks for noting my wish “Let our foremost commitment be: To do healthcare better. Let us work together.”
- I don’t think I see anything in this draft about amnesty for discovered errors. (I see whistleblower but not amnesty.) Without this I don’t think we have a prayer of the industry accepting this, do we?
- In open item #6 I do see “relationship between incident reporting and liability” but I don’t think that’s an open issue – I think it’s open and shut. As I said on my cover page, “let us do what encourages improvement.” Without amnesty, data transparency will be understandably feared by hospital boards and staff.
Regarding the open issue of extending whistleblower protection to IT safety issues, I cannot imagine an argument against this. Lives are at stake. Who will stand against any policy that will improve our error rate? I know some will, but I think it’s time for both types of “victims” to stand up – and I mean both the patients and the physicians who want better tools. Because as I learn about healthcare, increasingly I find physicians who are frustrated by things that hamper getting their jobs done.
Finally, this all seems especially current with recent news on the patient safety front:
- Paul Levy’s blog yesterday noted that last week the Lucian Leape Institute at the National Patient Safety Foundation released a report saying “medical schools and teaching hospitals have not trained physicians to follow safe practices, analyze bad outcomes, and work collaboratively in teams to redesign care processes to make them safer.” How scary is that?
- Macarthur Fellowship recipient Dr. Peter Pronovost, medical director of Quality & Safety at Johns Hopkins, was in the Times last week http://www.nytimes.com/2010/03/09/science/09conv.html, talking about how arrogance and ego get in the way of adopting methods that have worked in other industries. That’s a huge red flag for health IT.
- Pronovost is the author of the checklist approach that has massively reduced central line infections. As someone who’s had 28 days of central line insertions, I’m grateful. Yet most hospital still resist this simple, no-cost improvement.
- Business Week noted that reasons for this failure include “Many physicians do not like being monitored by nurses or otherwise being forced to follow a checklist” and “A wish to avoid standardized tasks and bureaucracy.”
Ironically, this all leads me to think that healthcare is too important to be left in the unconstrained hands of the healthcare industry.
For our own sake, we need to provide guardrails. And the least expensive, most motivated force we can introduce is the patient/family’s eyes, double-checking what’s in the record.
Today. We don’t need to wait years.
“The fundamental problem with the quality of American medicine,” Pronovost said, “is that we’ve failed to view delivery of health care as a science.” Last week in the quality improvement retreat I attended at Beth Israel Deaconess, a resident nailed it: “Boy, if we’re neglecting useful knowledge from other professions, that’s unscientific.”
Thank you again for the opportunity to participate. We can do great things.
Great stuff, Dave. It’s proven very helpful when healthcare adopts practices from other industries, like lean manufacturing and Crew Resource Management (from aviation). It’s a shame to let ego get in the way of science and what’s best for patients. I like your idea of having amnesty for errors in the records. We want quality information, but timeliness is important too. Hopefully there are longer term fixes to provide quality and speed with sharing of records.
Patient spotting errors: That is an embarrassment to the practice, and EHR implementation is not making the problem any worse. By getting an extra 48-96 hours, does anyone think all errors will be resolved? Small practices have hardly any time to complete the note, let alone fix errors.
Agree with your point that letting the patient see records on demand is better. Errors may be spotted and corrected faster.
Have the practice and patient work as partners and not adversaries.
This not a retail shop where shopper gets a discount when the clerk forgets to offer a receipt.
Yes, Abhi: partners, not adversaries. That’s what we consistently say on this blog – that’s what “participatory medicine” is about.
My previous post (linked above) discussed that this is about patient safety – finding errors. And the testimony I submitted (also in the previous post) said that to support a common goal of better quality, we should grant amnesty for errors found in the record.