Wednesday, November 18, 2009

Lack of Informatics support in ARRA/HITECH

I recently had this discussion on, and thought it would make a good post.

The topic was about ARRA/HITECH (what else?), and I commented that I didn't think the country was ready from an informatics perspective. My evidence : The number of times doctors confuse q12h with BID.

(A simple experiment you can try yourself : Walk into your local pharmacy and ask the pharmacist how often they get scripts which confuse the two.)

Anyway, on, a consultant asked me :

"Hi Dirk--
I'm wondering if you could explain a bit more your statement: "The problem is teaching docs the difference between "BID" and "q12h"." Are you saying that docs need to be trained to know the terms are different, and when to use each, or are you saying they're essentially interchangeable, and structured documentation would benefit from uniformity and choosing one as the standard? Would like to hear more of your perspective, and how informatics should be implemented. "

... To which I replied :

So glad you asked! (Remember, my advice is free, and you get what you pay for!) :)

Anyway, "BID" and "q12h" - These are very, very different terms medically. Only problem is, they LOOK very similar.

BID essentially means "Twice a day", and q12h means "Every 12 hours".

Get the difference? If you're a little puzzled about the difference, you're perfectly normal. I can tell you a LOT of docs struggle with the difference too.

BID technically, as "Twice a day", means generally 8am and 8pm. (In some hospitals, it means 10am and 10pm). But in most hospitals it means 8am and 8pm.

So if you write "Give Flagyl 500mg PO BID", the nurses will give it at 8am and 8pm. If you write the order at 1am in the morning, the first dose will get given at 8am -- 7 hours from when you wrote the order.

"q12h" technically means "Every 12 hours" - So if you write "Give Flagyl 500mg PO q12h" at 1am in the morning, the first dose will generally be given soon (maybe 2am?), and the next dose will be 12 hours from now (2pm).

Unfortunately, a surprising number of doctors don't understand this basic tenet of prescribing drugs. We only find this out when we "go electronic" and suddenly some doctor comes with a complaint : "I wrote for Flagyl 500mg PO BID at 1am and the drug didn't get given until 8AM??!?!?!"

I'm the guy who sees all these problems. So I'm the doc who has to tell the other doc, "Uh, you know that there's a difference between the two, right?" And then I'm the doc who sees their face, and the inevitable follow-up comment : "Well, I always USED to write it like that, and we never had this kind of medication delay before...This system stinks!"

And then I'm the doc who sees the truth : In the past, docs would write this, and pharmacists and nurses would just *compensate* for what we're doing - "Oh, Dr.Acme wrote for Flagyl 500mg PO BID for that patient admitted with C.diff at 1am - Of course he meant it to start now, so we'll really change it to q12h!"

We can all look at this and say "Well if there is JCAHO-mandated medication verification in pharmacy, then the pharmacist should have changed Dr. ____'s order to q12h" - The problem is that most pharmacists are physically separated from the patients, and have no way of really knowing why the patient is being admitted - A *very astute* pharmacist might question "Why would they order an antibiotic at 1am to start at 8am?" and perhaps call for clarification before approving the order - But unfortunately, this requires a very astute pharmacist and a significant amount of extra steps.

So... "What we have here is a failure to communicate"... The doctor didn't really understand the difference between q12h and BID, and a medication delay resulted.

The doctor will usually blame the software, when it's really a basic medication ordering problem. The doctor will also usually say "This worked better on paper", and he/she is right, it did work better on paper, because we all used to have more wiggle room and flexibility, and a lot of nurses and pharmacists would compensate for the doctor's mistakes. (Ask any nurse or pharmacist about this phenomenon, I'm sure you'll hear lots of stories.)

So, yes, we can give away the technology, but there is a lot of learning and culture shift that needs to take place, or else the doctors won't be happy with the outcome of going electronic.

This is where Clinical Informatics comes in, and I've written about Jedi Informaticists in the past to help fill this role (see the AMIA 10x10 class which is a quick way to get a Clinician up to Jedi speed), but I don't see much talk about "How we're going to pay for the Informatics to support this technology" in the ARRA/HITECH bill. Nor do I see that we have enough Jedis to make this transition successfully.

By the way, your question : "Are you saying that docs need to be trained to know the terms are different, and when to use each..?" - Yes, that's exactly what I'm saying. My post above explains the difference between the two pretty well, I think. Now if you could just get every doctor in the country to read my post, that'd be great. :)

(Oh, and the next time there's some "clinical compensation" phenomenon we uncover, I'll have to explain that too - And if you could just get the docs to read my next post, that'd be great too.) :)

Unfortunately, informatics isn't taught in medical school. And they didn't need to teach it when hospitals were on paper - Everyone just compensated for the docs with regards to these things. Now we need embedded clinical informaticists ("Jedis") to help rescue this situation, or else these docs will forever be unhappy with the outcomes of "going electronic".


rvaughnMD said...

1. Other than preop antibiotics why shouldn't all inpatient doses of antibiotics start now?
2. How can you track the frequency of this error - relying on occurrence reporting is notoriously weak; by making all doses (by policy) changed by nursing and pharmacy to include a now, you could report on any drug in the class of abx if not given with a now.
3. It is unrealistic to expect that physicians will suddenly start ordering correctly 100% of the time. All med orders should be verified and an explicit understanding of what pharmacy will routinely change and what is considered an error worthy of remedial action needs to be communicated regularly.
4. Steroid tapers and antiepilepsy drugs that vary in dose during the day are difficult to order electronically as a SINGLE order; using order sets for these is counterintuitive. Should these be 'free text orders' or should they be routinely repaired by the pharmacists?
5. IV fluid orders with additives are also difficult to order - same questions

Dirk Stanley, MD, MPH said...

All great points -

What you're getting at is the need for new clinical policies to address these issues.

You're right : Expecting docs to do this 100% correctly at day one is just unrealistic. But asking a pharmacist how often they see "BID" and "q12h" interchanged is a good way of getting a sense of how big a problem this is.

This is part of the culture shift that an EMR brings to doctors. If your administration isn't ready for the culture shift, and don't support the informatics effort, then your transition to an EMR is going to be rocky, no matter which system you buy. (In my humble opinion.) :)

Dirk Stanley, MD, MPH said...

Oh, and as for steroid tapers and IV fluids :

Free text brings its own problems.

If there answer is going to be either :
1. Docs properly ordering tapers/IV fluids OR
2. Order sets to address tapers/IV fluids.

... then this education is another thing the administration is going to have to tackle.

(You'll notice the recurring themes : Increased education, good policy mechanism - These are needed for an EMR to succeed, no matter which system you buy.)