Current Affairs

Mandating Masks at Schools When the Infectivity Rate Goes Up: A Responsible Action

I am a 61 year-old ER physician who has worked at a pediatric ER in Dallas-Fort Worth for 30 years.  At my job I take calls from other ERs across North Texas who have critically ill or injured children that need admission to a pediatric ICU.  For 30 years I have always accepted those transfers.  But multiple times I’ve recently had to turn them down because our ICU is “full” (no more beds).  We then help send those critically ill children to West Texas, Arkansas, New Mexico, Oklahoma or wherever a pediatric ICU bed can be found.  

How would  you like to be the parent of one of those children sent hundreds of miles from home? 

And if you are a school superintendent or school board member, how does this real-life story from the frontline make you feel about supporting school policies that allow unvaccinated, mask-less people around the children you are responsible to care for?

Bed shortages this severe did not happen before Covid-19.  The pandemic is real (come visit the ER to see for yourself), vaccines work (nearly all hospitalized are unvaccinated) and masks have been proven to reduce the risk of infection for over 100 years (since the 1917 pandemic).  They work, and that's why you expect your surgeon to wear a mask during surgery to prevent the germs in their mouth and nose from getting into your surgically-exposed body.    

Mandating masks makes sense when the infectivity rate goes up.   

Are you and your school districts going to be part of the solution, or part of the problem?  

Solution

 


Vaccine Mandates, Hyperbole and Hypothesis

Today my hospital’s leadership mandated Covid-19 vaccination.  Get vaccinated, or get terminated.  I get it, and I love it!

It is an ethical decision for us to get vaccinated-- to protect the children we serve, and also to do our part to give the virus fewer victims to infect (because as more people get infected, higher goes the risk for the virus to mutate into a more dangerous or even resistant variant).

For your friends and acquaintances who are hesitant about vaccine safety, there’s a lot of clear information in the message my hospital delivered today: Cook Children's Health Care System Mandates Covid-19 vaccination

Regarding the potential for long term side effects from Covid-19 mRNA vaccines, I like this article from another children's hospital, Children's Hospital of Philadelphia:   Covid-19 vaccine safety

 

My two-cents worth regarding the speed with which these Covid-19 vaccines were developed and approved for use:

The pandemic gave research scientists an unprecedented number of people around the world who eagerly volunteered to be trial patients to test the vaccine; the worldwide prevalence of the infection also created an environment where a large percentage of these trial patients quickly got exposed to Covid-19.  Within a remarkably short period of time, a significant number of trial patients who got the placebo instead of the vaccine got infected.  These conditions greatly shortened the time it took for research studies around the world to reach the statistical degree of confidence needed to affirm vaccine efficacy and safety--the same level of confidence as previous vaccine studies that took a decade or more to develop and test!  Its not hard to imagine vaccine trials taking longer to draw statistical conclusions for diseases that are much less prevalent than Covid-19.  In addition, the mRNA technology allows new vaccines to be developed and scaled up in an exponentially shorter time than the previous methods of vaccine development.  Prior to Covid-19, this technology had fortunately already been used for more than a decade in the development and testing of other vaccines, so it did not have to be built from scratch when the novel coronavirus sprang loose.

And, please, can people just stop being so gullible to all those bizarre vaccine myths?  When seeking the truth about the vaccines I personally have high confidence in the conclusions of research scientists who are paid to make hypotheses and then design studies to prove or disprove those hypotheses.  If they do so in an unethical manner, they lose their jobs.  Plus, I can look at the data myself if I want further proof.  I have actually looked at some Covid-19 research data, and IMO it is solid.  On the other hand, I am always highly skeptical of any information provided by TV and social media pundits who are paid to get high ratings.  Rather than designing studies to prove hypotheses, they design rhetoric to create hyperbole.  Hyperbole is exciting.  But hyperbole is opaque and dangerous.   Proving hypotheses is boring.  But the conclusions are transparent and tangible. 


Getting the COVID-19 shot is A-OK!

Getting your Covid-19 vaccine shot is “A-OK”—an Act Of Kindness.  And it is a broad, intentional act of kindness rather than a  narrow, random  one! 

I am an ER physician.  Here I am today being kind to my wife, my 96 year-old mother and anyone else who would be vulnerable to COVID-19 if I unintentionally infected them:

Covid shot #1 121920

I  hope others share my feelings of excitement and confidence in the vaccine’s safety and effectiveness.  My own confidence stems from “insider” information from my son's fiancé, a biostatistician working on COVID-19 research studies, and my own observations as  I followed vaccine research progress this year.  I saw no shortcuts taken--just brilliant  scientific research within an environment of reduced bureaucratic red tape-- and a little bit of educated luck sprinkled in.  A truly astounding achievement!.

#A-OK  #WeAreCookChildrens


Because of the pandemic, because of the election, I pray

The 2020 presidential election was held only three days ago.    Since then:

  • The number of daily new cases of COVID-19 in the United States has been exponentially increasing, now nearing 120,000 new cases each day
    • because of the pandemic 
  • The number of people dying each day from COVID-19 is increasing 
    • because of the pandemic 
  • The presidential race remains extremely close
  •  An unprecedented number of people mailed their ballots rather than risking exposure to COVID-19 by going to a polling place
    • because of the pandemic 
  • So most of the votes currently being counted are the mailed ballots
    • because of the pandemic
  •  Local elections officials have a shortage of poll workers
    • because of the pandemic 
  • So it is taking a really long time to tally the votes  
    • because of the pandemic 
  • And election results in 5 closely contested states remain too close to call
    • because of the pandemic 
  • After Trump began fanning conspiracy theories about voter fraud this past summer by denouncing mailed-in ballots and asking his followers to vote in person, he is now proclaiming victory and declaring voter fraud with no evidence of broad-based or systemic fraud
  • After Biden encouraged voters to vote early or mail ballots to reduce risk of exposure to COVID-19, he is now winning the majority of mailed-in votes still being counted and is gaining on Trump in all the contested states
  • Biden has asked Americans to be patient while legally casted votes get counted
  • In the past 12 hours Biden took the lead in 4 of the 5 closely contested states after the lead apparently flipped in 2 of them 
  •  Americans in general, and the news media in particular, have understandably been mesmerized by the presidential election and lost focus on COVID-19 even as new cases are reaching critical levels 

So this is what today, November 6th, 2020, is like:

  • A chaotic election, the result of which will have a profound impact on how America addresses the pandemic
  • A pandemic with exponentially rising rates of new daily infections which will have a profound negative impact on the economy for decades to come

How well we respond to the pandemic has direct correlation to how negatively the economy is affected.  For decades.  

 

I pray for America and our elected leaders.


WEAR a MASK and Don't Pee on Me!

When one is exposed to coronavirus floating around in the air while wearing a mask, naturally there will be fewer germs that get through the mask to one's nose and mouth than if one is not wearing one.   This is critically important, because emerging data suggests that being inoculated by a fewer number of germs at the onset of infection results in milder disease and more asymptomatic disease.  This is good news.  It may turn out that wearing masks to decrease the initial inoculum of germs is a more effective way to manage this pandemic than by locking down society.  

But this works only if we can effectively change people's attitude and behavior to always wear masks in public, and to NOT bow down to uninformed political statements or "patriotic" feelings about personal freedom.  Otherwise we end up risking more government-enforced shutdowns.

Stop at red lights,

don't take a loaded gun on a plane,

don't pee on someone sleeping on a public park bench

and WEAR a MASK!!!   

It's just what American citizens have to do during this pandemic.  It is not within your right to put my life at risk by running a red light, shooting a gun on a plane or infecting me with coronavirus.   And don't pee on me either.  That's gross.  You have NO right to threaten me or wetten me like that!

#LetsKeepOtherSfeAndDry


Dear Parent Who Refuses to Immunize Your Children: Are Going to Refuse the COVID-19 Vaccine?

Dear parent who refuses to immunize your children:

None of us are immune to the COVID-19 virus, so it is rapidly spreading through our communities causing unimaginable changes to our lives.  This infectious disease is directly impacting your family.  Neither you nor your children nor their grandparents are immune.  Although your children are not in the age group considered at higher risk for severe illness, their grandma and grandpa are.  So if your children get a fever or cough this week, be sure to keep them away from your parents.  Also, since you are not immune, you can catch COVID-19 from your kids.  When you get infected, you may not feel any symptoms for 2-14 days, but during that time you are infectious and can spread it to other people, like your parents.  So if your children have a fever and cough, you should stay away from your parents for at least 14 days AFTER your children get well.  Your parents at much higher risk of death from COVID-19 as compared to the flu, so please protect them.  And take care to protect yourself, as your risk of dying from COVID-19 death is higher than for your children.  And even though your children have a very low risk of dying from COVID-19, it is not a zero chance.

You can clearly see how devastating this infectious disease is impacting your family and our society. When is it going to stop?

When a child or parent recovers from COVID-19, they will likely have at least temporary immunity to it.  Once 50-80% of us have been infected and gain that immunity, the virus will have difficulty finding a human host to infect.  This is called “herd immunity”.  Herd immunity will result in the death of the COVID-19 epidemic.  It is possible that it will re-emerge later if herd immunity drops down too far.  At this time we don’t know for how long we will individually remain immune to COVID-19 after recovering from it.

But when a vaccine becomes available, we will be able to artificially induce immunity in our children, ourselves and our parents. And if boosters are needed to prevent herd immunity from dropping, we will be able to get booster shots.

One thing for sure is that you don’t ever want to live like this ever again.

But the truth is that this is actually NOT unimaginable. This was once polio. This was once measles. This was once whooping cough. This was once rubella. Haemophilus meningitis. Meningococcal meningitis. Diphtheria. Tetanus. Pneumococcus.

Currently our society is protected against these infectious diseases because we can artificially induce immunity through childhood vaccines. But your children are not protected against them.  And if enough parents refuse to immunize their children, the herd immunity in our society will fall below the level needed to prevent the next infectious disease epidemic.  The next epidemic could be polio, measles or pertussis.  Children and adults can die from diseases we can prevent through vaccinations, in some cases with higher death rates than COVID-19.

So when a COVID-19 vaccine becomes available, are you going to refuse to immunize your children?  And are you going to continue to refuse to immunize your children against the other infectious diseases that used to cause epidemics and kill people?  If so, just know that your fears are placing your parents and other children at risk of dying from a preventable disease.


Autonomic Angst Conjured By The Word-Which-Must-Not-Be-Spoken to Physicians

If while speaking to a group of physicians you use the word “provider” before you come to your important point, you will never get your point across.  In fact, you may not even get another sentence in, such is the autonomic angst conjured by the word-which-must-not-be-spoken

Most physicians resent being called the word-which-must-not-be-spoken, and some are instantly enraged by it.  Protect your valuables should you let it slip out of your mouth.  It is felt by physicians to be demeaning and disrespectful.  There are many reasons given for this, but I think the root cause is that the word-which-must-not-be-spoken is intertwined with bureaucratic red tape that has increasingly constrained the practice of medicine, especially over the past decade.  For example, the CMS Meaningful Use, PQRS and MIPS payment programs are all written for “eligible providers”.   Literally thousands of pages of rules, regulations and policies that impact the day-to-day activities of those who are said to be a word-which-must-not-be-spoken.   

Who wouldn’t resent such a word?

This happened because the word-which-must-not-be-spoken was adopted by policy writers for the rules and regulations associated with Medicare and Medicaid, as well for private insurance payors, to lump together all of the clinicians they pay for providing health care services to their clients.  To make it easier to write such regulations and policies, a single word was chosen to describe all the people that this word intentionally lumps together--physicians (M.D.s and D.O.s), nurse practitioners, physician assistants, podiatrists, chiropractors, dentists, anesthesiology assistants, audiologists, certified nurse-midwives, certified registered nurse anesthetists, clinical nurse specialists, clinical social workers, occupational/physical therapists, psychologists, registered dieticians and speech language pathologists to name a few. 

It sounds reasonable to lump all those people in with one word when writing policy rather than writing the whole list every time, doesn’t it?  But the word-which-must-not-be-spoken has unfortunately spilled out of regulatory-speak into common vernacular.  Personally, I can verify that after reading a 400-page CMS rule where the word-which-must-not-be-spoken is used over a thousand times,  it gets imprinted on the brain and difficult to avoid using for several weeks afterward.  So now PCPs are not primary care physicians anymore, but instead are called primary care words-which-must-not-be-spoken

So, one may ask, why did the policy writers not call us clinicians instead?  That would be more palatable. 

Well, the issue is that CMS and private payors also pay “entities” such as acute care hospitals, long-term health care facilities, physician practices and other clinical facilities and practices.  All of these entities are also considered to be “providers”, but they are not clinicians. 

Since entities do not have independent thoughts or feelings, they are not offended by the word-which-must-not-be-spoken, so you can call them providers without fear for your valuables.  In my opinion, it would have been better for policy writers to differentiate clinicians (people providers) from entities (facility providers), but that boat left the dock more than a decade ago.

I admit to being rankled for many years by the word-which-must-not-be-spoken, but I've gotten over it.  If one ignores the connotation of the word due to its overuse in bureaucratic red tape, it is really not such a bad word.   In fact, look it up in the dictionary, and you will see it is actually a word one should be proud to be called. 

Although I understand the autonomic angst conjured by the word-which-must-not-to-be-spoken, as it has been thoroughly butchered by government policy writers, at the end of the day call me a "provider of quality healthcare" and I'll go home happy.

Or just call me "Matt".


Matt Murray, M.D.

Provider of Quality Healthcare

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Although the behavior of one EHR vendor was wrong, more serious problems are inflicted by government-run EHR certification criteria

This week eClinicalWorks resolved a lawsuit by agreeing to pay $155 million for falsely claiming it met Meaningful Use (MU) EHR certification criteria.   Although the alleged behavior of eClinicalWorks was wrong, we have much more serious problems inflicted by the government-run EHR certification criteria.  

The business of EHR vendors is to gain clients and earn profits.  Developing innovative tools that help physicians care for patients should be the primary focus of their business.  Instead, vendors are held hostage to government-run certification criteria that are constantly changing and sometimes ambiguous.  While I do not condone the apparent behavior of eClinicalWorks, I am much more concerned about the  certification processes that led to this situation.   

The certification process evolved out of the 2009 HITECH Act that promoted the use of EHR technologies by offering incentive payments to hospitals and physicians who successfully adopted and used EHRs.   This resulted in an unprecedented rush of business for EHR vendors.  While EHR vendors began ramping up resources to meet the demands of the sales cycle and EHR implementations, they were also hit with government-imposed EHR certification criteria--criteria that are still changing frequently and sometimes are ambiguous.  This exponential increase in EHR client demands along with rapidly changing certification criteria crushed EHR vendor resource availability.  This constraint on resources forced them to focus on developing and testing EHR products to meet the specific certification criteria required by the government.  In my opinion, the unintended consequence of overwhelmed EHR vendors is that they then did not have available resources to focus more on:

  1. Improving usability
  2. Identifying and managing patient safety risks inherent to EHR use
  3. Developing innovative tools and functions that actually improve how physicians care for patients 

As a result, EHRs were developed to meet MU EHR certification criteria, but failed to improve poor usability.  EHR products could meet certification criteria, yet fail to adequately address patient safety risks associated with implementation and use.  And the constraint on EHR vendor resource availability remains an impediment to the development of innovative tools and functionalities that EHR vendors really should be focusing on today.

Physicians do benefit from EHR certification by reducing risk during the EHR selection process.  That is why the Certification Commission for Health Information Technology (CCHIT) was created in 2006 as an independent, not-for-profit group.  CCHIT certification was based on a consensus of stakeholders who determined core functionalities that a basic EHR should provide.  I participated in that effort, albeit in a brief, very small way (providing some input on pediatric core criteria).  I recall we were careful to avoid requirements that could hinder EHR product innovation.  CCHIT ceased operations in 2014 after the government created the MU EHR Certification program.  

CCHIT certification was much less prescriptive than what the government imposes today.  Less prescriptive EHR certification was, in retrospect, the right approach to take.  And we did it without government involvement.  Government works at its own hindered pace, and that pace is much slower than what an unencumbered EHR market could accomplish.  I think the government needs to get out of the EHR certification business.   But whether government remains involved or not, the EHR certification process needs to learn from CCHIT and rely more heavily on building consensus of physician stakeholders.  We will do what is best for our patients.    

So, this week one vendor was called out by the government for false claims regarding EHR certification.  But that one vendor is really not the problem.  The real problem is that the development of all EHR products has been, and still is, impeded by the government's EHR certification program.  

Matt Murray, MD

cook children's health care system..


Here we go again, forcing physicians to use technology that is not yet mature

Here we go again, forcing physicians to use technology that is not yet mature.  Texas House Bill 2743, if adopted, would require physicians in Texas to use electronic prescribing (e-prescribing) for controlled substances.   

While I agree with the goal (physician adoption of e-prescribing for controlled substances), the proposed tactic imposes requirements on the wrong stakeholder.  If e-prescribing tools and associated work flows were intuitive, effective, seamless and safe, then there would be no need to require physicians to use e-prescribing.  Physicians naturally gravitate toward technologies that are easy-to-use, safe and effective or time-saving.  I don't see many physicians writing checks now that debit cards are easy to use nearly everywhere we go.  The adoption of robotic surgery and MRI scans come to mind as well.

So to reach the desired goal, should not the state representatives instead require e-prescribing vendors to bring mature, useful products to the market?   Should we not require NCPDP, the organization that develops standards for script transmissions, to more rapidly develop standards needed to close gaps in current functionality and usefulness?  

My ER patients rarely prefer a written paper prescription.  But sometimes the patient wants a paper Rx because they just came from out-of-town, or they want to shop around for a 24-hour pharmacy in the middle of the night, or for other occasional, sometimes unusual reasons.  One of my patients preferred a written prescription because she liked how prescription paper smelled.  You might successfully guess the category of medication she received.  

It is rarely in the best interest of  my patients for me to write a prescription rather than to e-prescribe one.  Unless my e-prescribing system is down, or my patient tells me they prefer a paper prescription.  Or if I'm prescribing a narcotic, because my EHR vendor has not yet enabled my e-prescribing system to do so.  In my case it will take a major upgrade to get that done.  And I have not yet gone to a Federally-approved credential service provider (CSP) or certification authority (CA) to be "identity-proofed" so that I can obtain a two-factor authentication credential or digital certificate which is required to use e-prescribing for controlled substances.  I'll go through that hassle when my vendor enables the controlled substance e-prescribing tool.  And that upgrade will cost my organization a lot to implement.  

In the doctor's real world e-prescribing tools are not easy-to-use, intuitive or hassle-free.  Instead they are cumbersome and remain prone to some easily-preventable medication errors. In the real world of the pharmacist, it is not efficient to manually transcribe  into their own system the e-prescription information I sent.  They might have to use two screens to accomplish that task, or they might print my e-prescription and then transcribe it into their system.  That printer is likely to be in the far corner of the room.

 So in the real world Texas House Bill 2743 makes little sense.  I urge our state representatives to focus their tactics on the real problem--immature e-prescribing tools and processes.   Stop imposing unnecessary risks on physicians and patient care.  

Matt Murray, M.D.                                                                                                                                                                 cook childrens 


Increasingly hazardous healthcare environment should urge Congress to create a National Health IT Safety Center

Discharge instructions for a child’s insulin dose were correctly entered into the electronic health record (EHR), but when the mother received the printed instructions there was a decimal point error resulting in a 10-times dosing error.  This error was fortunately noticed by the bedside nurse and corrected manually.  I reported this near-miss to the EHR vendor and they corrected the technical problem.  However, when I asked vendor representatives whether or not this problem was being corrected with other physician clients across the country, they informed  me that no other client had reported such a problem. 

This is analogous to a situation where an airbag explodes and sends shrapnel into your face.  You might ask the automaker whether this is a problem with their other vehicles.  They might tell you that they are not aware of others having the same problem.  However, in the transportation industry they are required to report safety incidents and near-misses.  These reports are collected, aggregated and analyzed by the National Transportation Safety Board (NTSB).  If NTSB notices a trend in airbag-induced shrapnel injuries, they will initiate an investigation.  When NTSB discovers a problem with a specific airbag that is used across multiple types of automobiles, not just the type you purchased in your own state, then they are authorized by Congress to make safety recommendations to help ensure the risk is appropriately managed across the industry.

This insulin dosing incident is one of many health IT-related patient safety risks I have encountered and resolved in collaboration with an EHR vendor.  When my experience is extrapolated to the experiences of all physicians and EHR vendors, the scope of health IT-related patient safety risks can be seen as immense.  But unlike the safety of interstate commerce produced by the auto industry that is overseen by the NTSB, the safety of interstate commerce produced by EHR vendors has no cohesive oversight mechanism.  

The lack of oversight for health IT-related patient safety incidents and near-misses creates a hazardous patient care environment that I believe is urgent for Congress to address. The threat is increasing because the Meaningful Use Program (MU) has led to an exponential increase in the use of EHRs and other technology.   As a result, physicians are assuming a higher level of risk and accountability for computer programs, networks and infrastructures that are increasingly used as tools to generate patient care actions and facilitate medical decisions.  Although health IT-related patient safety risks would best managed through a shared accountability between physicians and EHR vendors, the vendors are not currently held accountable for patient safety.  Furthermore, the aggressive MU timelines have required EHR vendors to make rapid changes to EHRs without sufficient time to align changes with efficient physician workflows or to improve the flow of data between systems.  As a result, EHRs are increasingly plagued by poor usability problems and  lack of interoperability between EHR systems--both of which are patient safety risks that physicians commonly encounter.

So it is time to urge Congress to create a National Health IT Safety Center that can implement an effective EHR safety program designed to reduce EHR-related patient safety risks.  Within this concept EHR vendors could be required to report patient safety incidents and near-misses to the Health IT Safety Center similar to how transportation safety incidents must be reported to the National Transportation Safety Board.   The Health IT Safety Center could collect, aggregate and analyze reported data.   It could have power to investigate incidents involving patient harm and require EHR vendors to make appropriate changes.  It could monitor near-misses to identify trends and risks.  It could coordinate with other agencies to develop and broadly disseminate educational information and tools that mitigate identified patient safety risks related to technology use.  

I also envision that this resolution would lead to an entity that has the authority and influence to drive improvements in EHR usability and

 
 

interoperability, which are the two most significant impediments to effective and meaningful use of electronic medical records.   

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