Comments on: The Windows Vista Effect http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/ A blog from inside the emergency department Fri, 19 Mar 2010 03:29:48 -0400 http://wordpress.org/?v=2.8.4 hourly 1 By: DE Teodoru http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/#comment-7083 DE Teodoru Fri, 27 Feb 2009 01:47:59 +0000 http://www.epmonthly.com/whitecoat/?p=2056#comment-7083 Dr. Green, as you know, the boards are taken on laptops with time limit, so it is hard to imagine MDs as computer incompetent. The real issue is that PHARMA is molecular and medicine is physiological. There is a mismatch between the physical exam and the rationale from Rx. As for lab values, radiologically they are static anatomy and the morpho-chemical values are really the responsibility of the MD. So, if your lab mixes up specimens and your patient who is hyperkalemic proves to be hyperglycemic, according to the lab results, your *CLINICAL* picture should tell you that the labs are a mix-up. So in the end, what you trust is exactly what my dad trusted 70 years ago: physical exam and history. Is that not closing the barn door after the horse got out? If we're going to be getting preventive medicine we need to bring science to the practice long before signs and symptoms and that takes time to learn, for which the MD should be paid, given that for his patient care time he is paid less per hour than a plumber. Everyone makes off like a bandit except the patient and the doctor. It's time to take out the profit motive because the only two ends that contact directly-- patient and doctor-- are the ones screwed by the profit motive of the rest of the path. MY idea is not so radical, it was proposed in the 70s and all that's left of it is the baloney CME credits required annually and the decade re-exam. Medical education should be systematic, like school, and time spent should be time paid since a doctor who understands what's new is not paid more than a doctor whose year of graduation from residency program shows by his practice of medicine. Physicians want to be as good at physical diagnosis as at molecular diagnosis. The time it takes to achieve that should be work time, not home time-- isn't the time spent with parents, wife and kids short enough already? Don't you agree? If you do, then I'm sure you agree that the scrib sheet in the pills package--more a legal than a medical document-- should be far more explicit and not just giving lists of side effects just so that no one can say "you never told me." I mean, headache, constipation, cough, etc are pretty hard to use as guides. A lot more pharmacology to explain why some do and some don't get side effects would be a lot more useful, n'est pas? Dr. Green, as you know, the boards are taken on laptops with time limit, so it is hard to imagine MDs as computer incompetent. The real issue is that PHARMA is molecular and medicine is physiological. There is a mismatch between the physical exam and the rationale from Rx. As for lab values, radiologically they are static anatomy and the morpho-chemical values are really the responsibility of the MD. So, if your lab mixes up specimens and your patient who is hyperkalemic proves to be hyperglycemic, according to the lab results, your *CLINICAL* picture should tell you that the labs are a mix-up. So in the end, what you trust is exactly what my dad trusted 70 years ago: physical exam and history. Is that not closing the barn door after the horse got out?
If we’re going to be getting preventive medicine we need to bring science to the practice long before signs and symptoms and that takes time to learn, for which the MD should be paid, given that for his patient care time he is paid less per hour than a plumber. Everyone makes off like a bandit except the patient and the doctor. It’s time to take out the profit motive because the only two ends that contact directly– patient and doctor– are the ones screwed by the profit motive of the rest of the path.
MY idea is not so radical, it was proposed in the 70s and all that’s left of it is the baloney CME credits required annually and the decade re-exam. Medical education should be systematic, like school, and time spent should be time paid since a doctor who understands what’s new is not paid more than a doctor whose year of graduation from residency program shows by his practice of medicine. Physicians want to be as good at physical diagnosis as at molecular diagnosis. The time it takes to achieve that should be work time, not home time– isn’t the time spent with parents, wife and kids short enough already? Don’t you agree? If you do, then I’m sure you agree that the scrib sheet in the pills package–more a legal than a medical document– should be far more explicit and not just giving lists of side effects just so that no one can say “you never told me.” I mean, headache, constipation, cough, etc are pretty hard to use as guides. A lot more pharmacology to explain why some do and some don’t get side effects would be a lot more useful, n’est pas?

]]> By: Donald Green MD http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/#comment-7069 Donald Green MD Thu, 26 Feb 2009 18:01:54 +0000 http://www.epmonthly.com/whitecoat/?p=2056#comment-7069 The real problem here is that the EMR industry thinks doctors are a bunch of electronic dolts and incapable of learning or taking some time to assure accuracy. It should be regular practice for physicians or other providers to have knowledge of interactions or have access to competent programs such as on UpToDate. We do not have to succumb to an annoying spoon fed type of homogenized medical care. The real problem here is that the EMR industry thinks doctors are a bunch of electronic dolts and incapable of learning or taking some time to assure accuracy. It should be regular practice for physicians or other providers to have knowledge of interactions or have access to competent programs such as on UpToDate. We do not have to succumb to an annoying spoon fed type of homogenized medical care.

]]> By: DE Teodoru http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/#comment-7059 DE Teodoru Thu, 26 Feb 2009 05:36:35 +0000 http://www.epmonthly.com/whitecoat/?p=2056#comment-7059 Long, long ago, in the era of PPOs-- before HMOs-- my dad told me that we only prescribe drugs out on market for at least five years. As a heavy reader of what's new I felt very frustrated. Rheumatology was a field where a lot of basic research was then going on but back then we offered little more than NSAIDs-- But boy, Ibuprofen 1gm per day for 60 days!!!!!!! Today we wouldn't do that. But I watched the whole Vioxx panel sessions and was most struck by the patients who insisted they would die if it got black boxed. Three years later I attended a lecture (in a fancy French Restaurant) where Merck invited, as the salesman told me, "a top name in rheumatologist" (actually a payed hack) lecturing on "The Difference Between Rheumatoid and Osteo-arthritis." All the guy did was rehash the Vioxx data and advised to give aspirin half an hour after NSAIDs in patients on preventive aspirin because platelets would become "sticky" again after that time. nothing new on who could and who couldn't take Vioxx. I was very upset and ate nothing. The others at my table hadn't heard the lecture but loved the meal. The point of that story is that clearly for some Vioxx is poison, for others it is life saving-- so much for the generic "best practices." All those TZD studies and meta-studies make a clinician wonder: what the hell? The answer came from the chemist who first developed the TZDs. He said: "Well, the patient should know that the drug is a joint venture between doctor and patient and that they are both taking chances with their lives."--Duuuhhhh! We are entering an era where your genes-- not "best practices"-- decide what you can and can't take. THERE IS NO GENERIC PHARMA "N" SUBJECT. The Genome Project is giving us a heads up that soon genes will be the essence of "preventive care." So, given that health care is making dividends for thousands of investors from the inevitable getting sick of insured people, how can you load the dice for the house with your genome analysis? There is no choice but to end the predatory carnivore days of the HMO investors. We need the ultimate "open" (named ID) genetic data to link to outcome. Just as the rich tailor their suits, we'll have to stop the get rich bias schemes of one size fits all of Pharma Inc and make the statistical link that leads to the molecular mechanism link that brings us into the medicine of tomorrow. Now physicians trained in physiology and a bit of biochemistry are going by the advice of the visiting drug salesman with the jazz ballet degree and the nice legs in the short dress that is sent to throw at them the "molecular" pharmacology babble of the pill's maker. We are helpless when all the various DNAs and RNAs are brought up that made this drug's case at phase I and the testing on Andean Indians somewhere in South America in phase II. Reagan's only crime in my book was to allow federally funded research to be patented by the academics and Pharma industry so we pay twice for the drugs. Now you getting sick is big bucks for a lot of people who sit on their asses waiting for their dividends. That's even worse than the jungle. Health Care, therefore, has to be a highly regulated vocation instead of a long chain of money makers. The internist at the bottom, for example, per MEDICAL ECONOMICS, makes less per hour of patient care than does a plumber. he/she is not the problem. The problem is that doctors are not payed to study but Madison Avenue is payed big bucks to dupe them in the bloom of their post-residency ignorance. So, a doctor seeing a WARNING only gets scared but doesn't know why, doesn't know what to ask the Pharma parrot and doesn't know how to say no the the patient insisting: I saw it advertised on TV last night and I am sure it's what I need. If Health Care has so much money for stupid ads, why don't it pool the money for REAL further physician continuing education so they don't panic in ignorance at all the "CAUTION"s? Long, long ago, in the era of PPOs– before HMOs– my dad told me that we only prescribe drugs out on market for at least five years. As a heavy reader of what’s new I felt very frustrated. Rheumatology was a field where a lot of basic research was then going on but back then we offered little more than NSAIDs– But boy, Ibuprofen 1gm per day for 60 days!!!!!!!

Today we wouldn’t do that. But I watched the whole Vioxx panel sessions and was most struck by the patients who insisted they would die if it got black boxed. Three years later I attended a lecture (in a fancy French Restaurant) where Merck invited, as the salesman told me, “a top name in rheumatologist” (actually a payed hack) lecturing on “The Difference Between Rheumatoid and Osteo-arthritis.” All the guy did was rehash the Vioxx data and advised to give aspirin half an hour after NSAIDs in patients on preventive aspirin because platelets would become “sticky” again after that time. nothing new on who could and who couldn’t take Vioxx. I was very upset and ate nothing. The others at my table hadn’t heard the lecture but loved the meal.

The point of that story is that clearly for some Vioxx is poison, for others it is life saving– so much for the generic “best practices.” All those TZD studies and meta-studies make a clinician wonder: what the hell? The answer came from the chemist who first developed the TZDs. He said: “Well, the patient should know that the drug is a joint venture between doctor and patient and that they are both taking chances with their lives.”–Duuuhhhh!

We are entering an era where your genes– not “best practices”– decide what you can and can’t take. THERE IS NO GENERIC PHARMA “N” SUBJECT. The Genome Project is giving us a heads up that soon genes will be the essence of “preventive care.” So, given that health care is making dividends for thousands of investors from the inevitable getting sick of insured people, how can you load the dice for the house with your genome analysis? There is no choice but to end the predatory carnivore days of the HMO investors. We need the ultimate “open” (named ID) genetic data to link to outcome. Just as the rich tailor their suits, we’ll have to stop the get rich bias schemes of one size fits all of Pharma Inc and make the statistical link that leads to the molecular mechanism link that brings us into the medicine of tomorrow. Now physicians trained in physiology and a bit of biochemistry are going by the advice of the visiting drug salesman with the jazz ballet degree and the nice legs in the short dress that is sent to throw at them the “molecular” pharmacology babble of the pill’s maker. We are helpless when all the various DNAs and RNAs are brought up that made this drug’s case at phase I and the testing on Andean Indians somewhere in South America in phase II. Reagan’s only crime in my book was to allow federally funded research to be patented by the academics and Pharma industry so we pay twice for the drugs. Now you getting sick is big bucks for a lot of people who sit on their asses waiting for their dividends. That’s even worse than the jungle. Health Care, therefore, has to be a highly regulated vocation instead of a long chain of money makers. The internist at the bottom, for example, per MEDICAL ECONOMICS, makes less per hour of patient care than does a plumber. he/she is not the problem. The problem is that doctors are not payed to study but Madison Avenue is payed big bucks to dupe them in the bloom of their post-residency ignorance. So, a doctor seeing a WARNING only gets scared but doesn’t know why, doesn’t know what to ask the Pharma parrot and doesn’t know how to say no the the patient insisting: I saw it advertised on TV last night and I am sure it’s what I need. If Health Care has so much money for stupid ads, why don’t it pool the money for REAL further physician continuing education so they don’t panic in ignorance at all the “CAUTION”s?

]]> By: Rogue Medic http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/#comment-7031 Rogue Medic Wed, 25 Feb 2009 12:04:00 +0000 http://www.epmonthly.com/whitecoat/?p=2056#comment-7031 The <i>You can't be too safe</i> people do not Understand that they are making things more dangerous for patients. They view the human decision as the weak point in patient care. They think that by eliminating individual decisions, they will prevent bad decisions. this is a much worse decision than all of the individual decisions combined. They think that constant alarms mean that everyone will be constantly alert. Constant alarms encourage us to ignore the alarms. The expansion of top secret classification means that almost everything is secret, so nobody pays special attention to the true secrets. the result is that the real secrets are less secure. Companies are insisting that computer passwords have upper case letters, lower case letters, numbers, and symbols in them. This will result in people writing the passwords down, so that they can remember. What could be less secure than a password that is written down? Then they require that you change your password every couple of months. The truth is that these risk managers do not understand safety or risk management. They are the most dangerous people to be making decisions about safety. Maybe they need to watch <i>Dr. Strangelove</i> - the original version of <i>Fail Safe</i>. The You can’t be too safe people do not Understand that they are making things more dangerous for patients.

They view the human decision as the weak point in patient care. They think that by eliminating individual decisions, they will prevent bad decisions. this is a much worse decision than all of the individual decisions combined.

They think that constant alarms mean that everyone will be constantly alert. Constant alarms encourage us to ignore the alarms.

The expansion of top secret classification means that almost everything is secret, so nobody pays special attention to the true secrets. the result is that the real secrets are less secure.

Companies are insisting that computer passwords have upper case letters, lower case letters, numbers, and symbols in them. This will result in people writing the passwords down, so that they can remember. What could be less secure than a password that is written down? Then they require that you change your password every couple of months.

The truth is that these risk managers do not understand safety or risk management. They are the most dangerous people to be making decisions about safety. Maybe they need to watch Dr. Strangelove – the original version of Fail Safe.

]]> By: Locums http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/#comment-6989 Locums Mon, 23 Feb 2009 23:41:55 +0000 http://www.epmonthly.com/whitecoat/?p=2056#comment-6989 I am renewing metformin and glipizide. 1)Warning one: duplicate therapy, risk of hypoglycemia. Sure. Click. 2)Warning two: no creatinine within 60 days. Who orders a creatinine on every diabetic every 60 days? Since when would insurance pay for that? Sure. Click. 3)Warning three: Are you sure? STFU. Click. I am renewing metformin and glipizide.
1)Warning one: duplicate therapy, risk of hypoglycemia. Sure. Click.
2)Warning two: no creatinine within 60 days. Who orders a creatinine on every diabetic every 60 days? Since when would insurance pay for that? Sure. Click.
3)Warning three: Are you sure? STFU. Click.

]]> By: Overrides of Medication Alerts in Ambulatory Care « The ACUTE CARE Blog: Non-Urban Emergency Medicine http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/#comment-6986 Overrides of Medication Alerts in Ambulatory Care « The ACUTE CARE Blog: Non-Urban Emergency Medicine Mon, 23 Feb 2009 19:35:32 +0000 http://www.epmonthly.com/whitecoat/?p=2056#comment-6986 [...] of Medication Alerts in Ambulatory Care Posted on February 23, 2009 by coptermedic From White Coat (EP [...] [...] of Medication Alerts in Ambulatory Care Posted on February 23, 2009 by coptermedic From White Coat (EP [...]

]]> By: toni http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/#comment-6881 toni Wed, 18 Feb 2009 02:23:32 +0000 http://www.epmonthly.com/whitecoat/?p=2056#comment-6881 We carry pocket alarms connected to pts tele monitors so that at all times we can hear if the pt's monitor is alarming. Problem is that they alarm so frequently for non-life threatening events that everyone just ignores them. Honestly I don't even hear them anymore. I can't tell you how many times someone says doesn't that noise bug you? What noise? Hospital spent alot of money on this system. I hit over ride on the pyxsis every time I work. It's a pain. We carry pocket alarms connected to pts tele monitors so that at all times we can hear if the pt’s monitor is alarming. Problem is that they alarm so frequently for non-life threatening events that everyone just ignores them. Honestly I don’t even hear them anymore. I can’t tell you how many times someone says doesn’t that noise bug you? What noise? Hospital spent alot of money on this system. I hit over ride on the pyxsis every time I work. It’s a pain.

]]> By: ERDocMark http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/#comment-6858 ERDocMark Mon, 16 Feb 2009 14:42:27 +0000 http://www.epmonthly.com/whitecoat/?p=2056#comment-6858 William is correct. This is the real problem of computer generated warnings. They put you on notice should some untoward effect actually happen. What is your defense? "I didn't know?" This just proves GIGO, garbage in/garbage out. When you see a record of an allergy that isn't a true allergy, it has to be corrected. The real benefit of EMR is not management of care, but access to a complete picture of the patients previous care. William is correct. This is the real problem of computer generated warnings. They put you on notice should some untoward effect actually happen. What is your defense? “I didn’t know?” This just proves GIGO, garbage in/garbage out. When you see a record of an allergy that isn’t a true allergy, it has to be corrected. The real benefit of EMR is not management of care, but access to a complete picture of the patients previous care.

]]> By: William http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/#comment-6847 William Sun, 15 Feb 2009 12:36:49 +0000 http://www.epmonthly.com/whitecoat/?p=2056#comment-6847 Out of ignorant curiosity, what is the potential for these medical records to be subpoenaed and then used against the provider? The thought of facing questioning about why I bypassed an automated warning on one of the computer systems that I work on is intimidating enough when I'm just risking a paycheck. I wouldn't be willing to stand up to legal questioning about bypassing a forgotten warning on a network that I worked on a year or two ago and don't remember clearly....... Can these records be retrieved by lawyers? Just looking for clarification. Thank you. Out of ignorant curiosity, what is the potential for these medical records to be subpoenaed and then used against the provider? The thought of facing questioning about why I bypassed an automated warning on one of the computer systems that I work on is intimidating enough when I’m just risking a paycheck. I wouldn’t be willing to stand up to legal questioning about bypassing a forgotten warning on a network that I worked on a year or two ago and don’t remember clearly……. Can these records be retrieved by lawyers?

Just looking for clarification.
Thank you.

]]> By: k http://www.epmonthly.com/whitecoat/2009/02/the-windows-vista-effect/#comment-6845 k Sun, 15 Feb 2009 04:28:05 +0000 http://www.epmonthly.com/whitecoat/?p=2056#comment-6845 Somehow, this reminds me of one of those movie trailer voiceovers: In a world where data is manipulated and mined to further corporate greed.. to abuse sick people and the physicians who treat them. A new day is dawning: panic... pain... torture... anguish... despair... denial. Just when you thought EMRs might provide some relief. Coming soon to a medical facility near you: ICD-10 - The Nightmare Somehow, this reminds me of one of those movie trailer voiceovers:

In a world where data is manipulated and mined to further corporate greed.. to abuse sick people and the physicians who treat them. A new day is dawning: panic… pain… torture… anguish… despair… denial. Just when you thought EMRs might provide some relief. Coming soon to a medical facility near you: ICD-10 – The Nightmare

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