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Hospitals and General Grant Have a Lot in Common

A few weeks ago, I was having a bad dream. Everything was turning black. It was hard to breath and moving was equally labored. It wasn’t a dream. I woke up and found myself working hard to inhale. Getting out of bed took determination.

I managed to get to our hallway and call my wife. She called 911 and DC’s paramedics soon had me on my way to Medstar’s Washington Hospital Center’s ER. They stabilized me and soon determined I wasn’t having a heart attack, but a heart block. That is, the nerve bundles that told my heart when to contract weren’t on the job.

A cardiology consult sent me to the Center’s Cardiac Electrophysiology Suite (EP Clinic), which specializes in arrhythmias. They ran an ECG, took a quick history and determined that the block wasn’t due to any meds, Lime disease, etc. Determining I needed a pacemaker, they made me next in line for the procedure.

Afterwards, my next stop was the cardiac surgery floor. Up till then, my care was by closely functioning teams. After that, while I certainly wasn’t neglected, it was clear I went from an acute problem to the mundane. And with that change in status, the hospital system’s attention to detail deteriorated.

This decline lead me to a simple realization. Hospitals, at least in my experience, are much like Ulysses Grant: stalwart in crisis, but hard pressed with the mundane. That is, the more critical matters became in the Civil War, the calmer and more determined was Grant. As President, however, the mundane dogged him and defied his grasp.

Here’re the muffed, mundane things I encountered in my one overnight stay:

  • Meds. I take six meds, none exotic. Despite my wife’s and my efforts, the Center’s system could not get their names or dosages straight. Compounding that, I was told not to take my own because the hospital would supply them. It couldn’t either find all of them or get straight when I took them. I took my own.
  • Food. I’d not eaten when I came in, which was good for the procedure. After it, the EP Clinic fed me a sandwich and put in food orders. Those orders quickly turned into Nothing by Mouth, which stubbornly remained despite nurses’ efforts to alter it. Lunch finally showed up, late, as I was leaving.
  • Alarm Fatigue. At three AM, I needed help doing something trivial, but necessary. I pressed the signaling button and a nurse answered who could not hear me due to a bad mike. She turned off the alert. I clicked it on again. Apparently, the nurses have to deal with false signals and have learned to ignore them. After several rounds, I stumbled to the Nurses’ Station and got help.
  • Labs. While working up my history, the EP Clinic took blood and sent for several tests. Most came back quickly, but a few headed for parts unknown. No one could find out what happened to them.
  • Discharge. The EP Clinic gave me a set of instructions. A nurse practitioner came by and gave me a somewhat different version. When we got home, my wife called the EP Clinic about the conflict and got a third version.
  • EHR. The Hospital Center is Washington’s largest hospital. My PCP is at the George Washington University’s Medical Faculty Associates. Each is highly visible and well regarded. They have several relationships. The Center was supposed to send GW my discharge data, via FAX, to my PCP. It didn’t. I scanned them in and emailed my PCP.

In last five years, I’ve had similar experiences in two other hospitals. They do great jobs dealing with immediate and pressing problems, but their systems are often asleep doing the routine.

I’ve found two major issues at work:

  • Incomplete HIT. While these hospitals have implemented EHRs, they’ve left many functions big and small on paper or on isolated devices. This creates a hybrid system with undefined or poorly defined workflows. There simply isn’t a fully functional system, rather there are several of them. This means that when the hospital staff wants to find something, first they’ll look in a computer. Failing that, they’ll scour clipboards for the elusive fact. It’s like they have a car with a five speed transmission, but only first and second gear are automatic.
  • Isolated Actors. Outside critical functions, individuals carry out tasks not teams. That is, they often act in isolation from those before or after them. This means issues are looked at only from one perspective at a time. This sets the stage for mistakes, omissions and misunderstandings. A shared task list, a common EHR function, could end this isolation.

The Hospital Center is deservedly a well regarded. It’s heart practice is its special point of pride. However, its failure to fully implement HIE is ironic. That’s because Medstar’s National Center for Human Factors in Healthcare isn’t far from the Hospital.

The problems I encountered aren’t critical, but they are troublesome and can easily lead to serious even life endangering problems. Most egregious is failure to fully implement HIT. This creates a confusing, poorly coordinated system, which may be worse than no HIT at all.

Note: This was first published on: emrandehr.com

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I’m Now a Thing on the Internet of Things

Thanks to a Biotronik Eluna 8 DR-T pacemaker that sits below my clavicle, I’m now a thing on the internet of things.biotronik-eluna What my new gizmo does, other than keeping me ticking, is collect data and send it to cell device sitting on my nightstand.

Once a day, the cell uploads my data to Biotronik’s Home Monitoring website, where my cardiologist can see what’s going on. If something needs prompt attention, the system sends alerts. Now, this is a one way system. My cardiologist can’t program my pacemaker via the net. To do that requires being near Biotronik’s Renamic inductive system. That means I can’t be hacked like Yahoo email.

The pacemaker collects and sends two kinds of data. The first set shows the unit’s functioning and tells a cardiologist how the unit is programmed and predicts its battery life, etc. The second set measures heart functioning. For example, the system generates a continuous EKG. Here’s the heart related set:

  • Atrial Burden per day 

  • Atrial Paced Rhythm (ApVs) 

  • Atrial Tachy Episodes (36 out of 48 criteria) 

  • AV-Sequences 

  • Complete Paced Rhythm (ApVp)
  • Conducted Rhythm (AsVp) 

  • Counter on AT/AF detections per day 

  • Duration of Mode Switches
  • High Ventricular Rate Counters
  • Intrinsic Rhythm (AsVs) 

  • Mode Switching
  • Number of Mode Switches 

  • Ongoing Atrial Episode Time
  • Ventricular Arrhythmia

Considering the pacemaker’s small size, the amount of information it produces is remarkable. What’s good about this system is that its data are available 24/7 on the web.

The bad news is Biotronik systems don’t directly talk to EHRs. Rather, Renamic uses EHR DataSynch, a batch system that complies with IEEE 11073-10103, a standard for implantable devices. EHR DataSynch creates an XML file and ships it along with PDFs to an EHR via a USB key or Bluetooth. However, Renamic doesn’t support LANs. When the EHR receives the file, it places the data in their requisite locations. The company also offers customized interfaces through third party vendors.

For a clinician using the website or Renamic, data access isn’t an issue. However, access can be problematic in an EHR. In that case, the Biotronik data it may or may not be kept in the same place or in the same format as other cardiology data. Also, batch files may not be transferred in a timely fashion.

Biotronik’s pacemaker, by all accounts, is an excellent unit and I certainly am glad to have it. However, within the EHR universe, it’s one more non-interoperable device. It takes good advantage of the internet for its patients and their specialists, but stops short of making its critical data readily available. In Biotronik’s defense, their XML system is agnostic, that is, it’s one that almost any EHR vendor can use. Also, the lack of a widely accepted electronic protocol for interfacing EHRs is hardly Biotronik’s fault. However, it is surprising that Biotronik does not market specific, real time interfaces for the products major EHRs.

Note: This was first published on emrandehr.com

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