In Conversation With… Vineet Arora, MD, MAPP
Approach to Improving Safety
Setting of Care
Editor's note: Vineet Arora, MD, MAPP, is Director of GME Clinical Learning Environment Innovation, Associate Professor of Medicine, and Assistant Dean for Scholarship and Discovery at the University of Chicago Pritzker School of Medicine. We spoke with her about the intersection of health information technology and patient safety.
Dr. Robert M. Wachter: When you think about the Venn diagram of patient safety and information technology (IT), what comes to mind for you?
Dr. Vineet Arora: I think of the intersection of decision support and tools that really make clinicians do the right thing at the right time at the point of care. For example, making sure that VTE [venous thromboembolism] prophylaxis is ordered, when best practice alerts are in the background. That would be the synergy where I see patient safety and IT working together: identifying a drug–drug interaction, for example. A lot of our residents like that feature in electronic health records (EHRs). But some complications also can occur with IT. Whenever IT substitutes for processes that require human interface, you have to be careful. Obviously the synergies are very important and for the most part outweigh the risks. It's important to be vigilant.
RW: As you look at some of the risks that have emerged, which are the most striking?
VA: One of the major risks with technology and EHRs is "garbage in, garbage out," and automating a bad system and making it worse. The way I see that most powerfully is in what we call "CoPaGA" syndrome—copy and paste gone amok—where it might say "Foley to gravity" several days in a row...and the patient doesn't have a Foley. Or, on the day of discharge, it looks like a patient is unstable because the note doesn't reflect the current vital signs, that the patient's sepsis has improved, and that IV antibiotics have been discontinued. As a primary attending who's seeing that, it's concerning because the EHR is the medical charge. People are looking at that documentation to make decisions and judgments, and it's a snapshot in time. But if your chart doesn't match what the patient looks like at that moment, you could have poor decisions.
I have done a lot of work in handoff communication and care transitions. People are often overreliant on the EHR for communicating information, particularly through in-baskets and in-messaging—a lot of this leads to information overload and information anxiety. As a hospitalist, I don't manage a primary care panel, but I see what the residents and my colleagues face in managing huge numbers of incoming lab results, etc. Even just managing a panel of hospitalized patients, my in-basket is overwhelmed with lab results from the patients' first set of labs to their final set of labs in the hospital. And I wonder could I have missed an abnormal result that needs follow up? Part of solving the information overload will be figuring out the human factors piece of presenting the information, as opposed to having clinicians try to adapt their brain and do the work to figure out which abnormal lab needs follow up. Those are examples of imminent dangers in the EHR.
RW: Let's go back to the note. You have a major role in training students and residents at Chicago. Do you see the fact that the notes have deteriorated as a problem in training and professionalism, or is it a technology problem? How would you address it?
VA: I would say it's a little bit of both, and our accrediting agencies are starting to realize that as well. An important piece of professionalism is to document truthfully. That is actually now part of the ACGME's new push on the Clinical Learning Environment Review program. They ask program directors, faculty, and residents, "How often do you see copy-and-paste errors in the chart?" I think we will start to unveil some national data around that.
When we had Epic being implemented several years ago, a senior clinician said, "I'm worried about the art of medicine dying. I spend a lot of time thinking about my notes, synthesizing the information, distilling it down to the really beautiful crisp summary of what's going on"—this was a cardiologist, a very esteemed clinician speaking about his concerns. And his concern bore out. The notes are certainly a lot worse and don't communicate that. They've become more like wikis. I always tell the residents, "I don't know why you're keeping all this information there; it's in the record." But "because they can" is the answer. They're concerned someone will ask them yesterday's creatinine or BUN. Maybe they've not yet graduated to the level of following the trends. They keep everything in their notes, when in fact it's pretty easy with a graph function to look at how the creatinine trended. Some of it is teaching our learners that it's important to use the electronic record to augment their learning, and they don't need to keep all the information in their note.
Back to the question about what the system does, some of the Epic leaders had suggested to our CMIO [chief medical informatics officer] at the time that we could turn off copy and paste, but you can imagine the revolt among clinicians that would take place?
I always teach the residents it's okay to copy and paste—but it's copy, paste, and update. The vigilance and the professional responsibility are to look at this information and make sure it reflects today's progress and is updated. In our day, when you were writing a note from scratch, of course it would be updated. You would never start with yesterday's note as a template for the assessment and plan because it's too long. We have to start teaching our residents to let go of some information and reteach them to synthesize at the point of care and try to write in their own words what's happening with the patient that day. So they're not left with this: on day one, the patient presented with fever; on day two we found this; now they have this; and now they're on this. That becomes a really long wiki that's not meaningful when you need to have the diagnosis right there, which is the patient has MSSA meningitis and is on antibiotics.
In some of our work reviewing signouts, we have seen long hospital courses that are overwhelmingly hard to learn and memorize, especially for a physician covering 50 patients. This is a mismatch where we have too much technology and not enough training on how to use it well. We have taken away this whole idea that note writing is still an art, and you still need to be able to do it well. Some places are working out how to do that better and I think the accreditation push will help.
RW: Let's turn to handoffs and signouts. How do you see electronic tools helping? You've talked about how they can get in the way if the note is terrible, but now specific tools have come out to try to improve signouts and handoffs. What do you think of that?
VA: I have always been a big fan of electronic tools to improve the handoff and basically not duplicating work. One of our early studies showed that in the old days people were transcribing medication lists, assessment, and plans and then just copying everything into Microsoft Word or Excel—and there were a lot of omissions and commissions, things left on the signout that actually were not happening anymore. So it was very confusing.
The greatest example is that the medication administration record (MAR) can populate the signout and the progress note, which removes the human error in transcribing. So electronic tools have great potential to improve signouts. The challenge is that people are still not satisfied with the tools they have. The worst-case scenario is when you implement the EHR, because of the inertia and the fact that nobody pays attention to the signout initially, the signout stays in a Microsoft Word shared folder somewhere. You have this great EHR, you should be harnessing it for safety, but these transcription errors still happen.
In terms of why people don't adopt, why is there not a dominant solution? It's because there's no one-size-fits-all for this. I'm often asked what's the one template that would work? I have worked with surgeons, hospitalists, residents—medicine and pediatrics—and everyone has a different philosophy of how much information they want. For example, the pediatricians want a lot of information, whereas the hospitalists really just need bare bones, and surgeons need even less than that. It's hard to create a standardized template, but what you really have to do is work with the front-end users to customize the template. We have done a lot of that work and have had some success, but it does take a lot of time. Years later, we have an EHR and our signout is built in the EHR, which was very important to our organization. But different models abound, and it's really just what the organization is comfortable with and what frontline users will use.
RW: Let's turn to diagnostic errors, an underappreciated corner of the patient safety world. People have been working for 30 or 40 years on helping physicians be better diagnosticians, electronically. What do you see as the state of those efforts?
VA: One of the hardest challenges, especially because diagnostic errors are very common and you can get a lot in ambulatory care, is really being able to follow that narrative of the patient. What did the chest x-ray show? What did the CT scan show? When did they get this test? When you're trying to figure out the diagnosis or you have a sense that this patient would benefit from a second look to understand what the right diagnosis is, one of the greatest challenges is assembling the information in a chronological way that makes sense to the physician. Partly it's because of the tab screens, and you can sort by consult notes or progress notes, but if you look at all the notes, you might get a physical therapy note in there. There's so much that it's hard to get through. We used to read notes like a book. We would flip the pages and it would be a chronology. Now what happens is you're opening a screen for each click, then you close it and you open the next one until you find what you're looking for. That can take a lot more time and energy. Obviously in our fast-paced health care environment, particularly in the ambulatory setting, that can be really hard. That's not even connecting the fact that the note's probably copied and pasted.
I recently did a morning report at Johns Hopkins Bayview Medical Center where we discussed diagnostic error. They told me about a case in which a test had happened 5 years prior, but it was buried somewhere in the EHR, and every time the patient was admitted no one saw that test. Finally some diligent intern looked far enough back into the EHR and saw it. So when you have your pre-review time with your EHR and you're doing your chart biopsy before you go see the patient, how far back are you looking? How many meds are you really looking at? Now we have so much information, but is there a way to organize it so that the top information goes to the top? This will be EHRs 3.0, where you will need human factors researchers, engineers, and people who specialize in visual display of information to really figure out how do you get people the information they need quickly?
RW: You spend a lot of time with younger clinicians and trainees. Talk about how different they are, compared with the older folks, in their use of technological tools.
VA: That's a great question. I would say that sometimes we assume that Millennials and the new generation know more than they should about technology. We gave iPads out to our residents pretty early on. We were one of the first residency programs to do that, studied it, and showed that it improved efficiency of our residents, their satisfaction, and their attendance at educational conferences and it was very well received.
Then we did some follow-up work looking at who really uses the iPad and to the top of their ability? Who's using apps? Who's using the iPad to teach patients at the bedside? All these great things that we could do with it. You cannot just assume that age is the trigger; a lot of people need help. They don't know which apps to use. We started with our super-user group, they need the same sort of education. Can we do a morning report on an app for cardiology? What are the right calculators to be using? We cannot just toss the technology out there and assume that if you're young, you'll be able to figure it out. There's Wild West right now with medical apps. You could really go down the wrong pathway if you're not using an app that the faculty endorse and the experts in the field say, for example, is a great app for how to look at liver disease and grade liver failure.
Interestingly, we found that after we gave out iPads, the percentage of residents who preferred pen and paper to organize their thoughts nearly doubled! My sense is that iPads are not the end all be all, and there is still a data entry problem with iPads. Although it works for point-and-click orders or look-up features, it is not the preferred way to enter a progress note. So in the future, I expect better interfaces will help doctors use mobile technology to complete progress notes.
In general, the younger generation expects technology at the bedside, and they demand it in a way that we need to meet them halfway. So when EHRs were coming in, it was a recruitment issue. The first question people would ask was "Do you have an EHR?" If you didn't, game over, you would be lower on that person's rank list. When EHRs were implemented, it was a great example of reverse mentoring. The residents would be creating smart phrases that they taught our attendings. Some of our attendings who needed some help with switching over got paired with one of these residents. That also highlights the need for a flattened hierarchy in our educational systems. Medicine and technology are changing so fast that we need to be able to open the door and say, "I could teach you medicine, but maybe you can teach me to be more efficient while I'm charting." That dialog has been very productive.
RW: Are you still giving out the iPads?
VA: We just gave out minis, so the residents are excited about having the mini in their coat pockets. It's really great for having the information at the point of care. Now on rounds they tell me there's a chest x-ray and I say, "Let's just look at it right now." It's more information-centered, instead of me telling you my interpretation. Let's all look at it together. What do you see? What do I see? So that has helped. We're doing an evaluation of faculty and resident perceptions and patient perceptions of the iPad. It's preliminary right now. Obviously the residents love the iPad, but the faculty always sense more of the nuances. Is your resident buried in their iPad? Are they listening to you? Some of the issues with Millennials come to the fore there: how do you get their attention when maybe they're stuck doing orders, then they moved on to seeing something else in Epic, and meanwhile you're trying to have a teaching session or a teaching point about a physical exam finding.
Abraham Verghese's work on the "iPatient" is really important to think about. Also trying to incorporate the patient's perspective. Patients do notice that clinicians are bringing these devices into the room. We have been examining what patients perceive about the residents having iPads. What do they think about wearable technologies? We're finding that patients support the technologies if they believe it helps their doctor. But they want to be sure that they, the patients, are being listened to. We're doing the same work with EHRs, going back to the basics. Are you looking at your patient when you're in the office with the EHR? We need to teach these new types of skills, which is that it's not just the doctor and the patient—it's you, me, and the EHR, or you, me, and the iPad. That level of complexity needs to be acknowledged in the doctor–patient relationship, and we need to teach people how to meaningfully use the technology while still preserving the doctor–patient relationship.
RW: You were one of the first and more prominent academic people in the social media world. Tell us about that and how you think it's transforming your relationships, education, and any other impacts that you're beginning to see.
VA: That was a fairly exciting movement to ride the wave of the early adopters in social media in health care. It's great to see it become more commonplace. The question for social media has always been: how do you prove its return on investment? Because it could be a time sink. If it integrates into your day, you're thinking about a teaching point and you tweet it out at the same time—you're learning, somebody else is learning. It replaces other time that you would have spent goofing off. Now one question I always ask is: how do you use social media to reach your learners or your patients?
The people I teach work with me in the hospital, so the best way for me to teach them is in person. Some preliminary work shows that while online modules, flipped classrooms, and all this stuff sounds exciting, without real-world field practice and face-to-face discussion, it doesn't transfer the same level of knowledge as an interactive discussion. Partly the reason is that a bad lecture will become a bad online module. We have not harnessed the principles of adult learning in medicine to drive that change. Similarly in social media, while innovative things are being done to engage patients and providers, the real value is reaching beyond the four walls of your institution—thinking about public health messaging or using tweets to identify flu outbreaks. In the Chicago Department of Public Health, a colleague uses tweets to identify foodborne illness outbreaks in restaurants, for example. So there are great applications in public health.
There's good professional development related to social media. I find plenty of information about social media that advances my own teaching, career, and research, so those are important things for physicians to know as well. There's still a fuzzy line regarding your presence as a physician on social media and what your obligation is. What if a patient is following you on social media? Certainly Facebook is more confusing to navigate. We authored an online professionalism policy paper for the American College of Physicians. If you're a physician, you have an obligation to disclose that fact and to highlight that social media is not the forum for professional advice. If somebody is seeking you out, you would need to send them to proper channels. You need to be aware that whatever you post will be seen. It's hard to divorce the fact that you're a physician there. It's something to keep in mind at least on a public medium like Twitter. If you have a private Facebook account, maybe you can get away with a little bit more.
But times are changing. I advise trainees to pause before posting. Be very conscientious—whatever you post can always be reposted, even if it's on a private network. The Millennial generation gets this because they've grown up with it. Our studies show a significant portion of people entering med school say they've asked friends to take down pictures of themselves, or they've seen pictures that they don't want up. They've been policing and managing their footprint from an early age in ways that we never had to do. The casual user is more likely to make a mistake. Somebody just starting a blog who's new to social media who might disclose the date and the disease of a patient they took care of but not the name, and they don't realize that's enough to make it identifiable.
Any time social media comes up it's kind of polarizing. Some people think it's great, and the institutional legal types will always be concerned. The answer is education, and we have been teaching people how to use social media through workshops in our institution. It's been fairly well received, you need to have the interest and the enthusiasm, but you also need to know what's acceptable and what's not.
RW: Anything else you wanted to talk about?
VA: Patients are expecting more now. They're expecting to see their notes and be partners in their care. That is driving a lot of change in medicine. We just opened the MyChart function of our personal health record. Where they're using OpenNotes [a program that allows patients to read their clinicians' notes], I do think it dramatically changes the way you write your notes, the way you think about the patient. Some innovative work being done at Kaiser involves looking at writing the note with the patient in the room watching the monitor on a big screen that the patient is looking at with you.
As we think about the future, patients will be expecting to have access to their records and be in control of their record in a way we have not seen before. This is being driven by patient advocates like Regina Holliday and Dave DeBronkart, who have experienced care and unsafe events, who have basically put their foot down in advocacy for patients to say the EHR is really theirs. That's challenging for our health care system to think about, particularly because we need to get our shop in order. We need to fix the copy-and-paste problem. We need to make sure that our notes reflect what's happening with the patient. I don't know what this will look like in the future, but I do think that patient transparency and involvement of patients holds great promise to dramatically change things.
RW: At least part of your time is spent in the training world. Do you think trainees now are learning what they need to about this new kind of patient? About how to use electronic tools? About how to write notes in an electronic environment? Basically how to practice medicine in the future that they're about to go into?
VA: The short answer is probably no. When we think about EHR training, our residents nationwide think of the sitting through 4 hours of grueling training on resident day, orientation number one, getting their ID, and figuring out how to write a note. In terms of interacting with this empowered patient movement, this is an area that I worry that our residents might be left behind in, because our residents still train predominately in teaching hospitals and they take care of the patients who are least empowered. When they move from that environment to one where patients are expecting more—I have seen this from several of our graduates and others who move into concierge primary care or new models of primary care—I think it's a big shock.
But the tide will turn quickly, and we're already seeing this in pediatrics. Our pediatric cancer patients are blogging about their experience while the residents are taking care of them. Pretty soon we will see that the next generation of seniors will all have smartphones. They will all be web savvy. People assume there's a digital divide, but low-income minority communities are more likely to have smartphones than a landline and more likely to access social networking sites than their counterparts. So while pediatrics provides a window to see how that works—there's some great work being done in mobile messaging and text messaging—a bigger question will come when the next generation of people age and they ask, you want me to fax you something?
RW: What's that? Right?
VA: That will be the tipping point for health care, when patients say, "Why can't you just text me?" Right now that's only happening on the edges, not in academia, but certainly it's happening in well-functioning practices in the community. When that starts happening in academia, that's where we will need to see a lot of change. Residents will have to learn how to interact with this new type of patient.
Previous interviews can be heard by subscribing to the Podcast