Stethoscopes, EMRs and EHRs – what is all the data worth? Volume 2

| April 4, 2008

I posted a previous note about the value of all clinical information derived from health system records in EMRs or PHRs here. This is volume 2 on the same theme.

Several years ago as an intern I was charged with caring for a patient who required a ventilator while in the cardiac care unit.  As the cardiologists at this institution were not comfortable caring for the ventilator needs of this patient, I was required to confer with the critical care/pulmonary ICU fellow that month for treatment recommendations.  Realistically, this patient probably should have been in the ICU altogether but perhaps for lack of a room was in the CCU.  Nonetheless, a large part of my efforts were spent trying to find the fellow when she was available for support.  Of course, she had twelve other patients to manage and was not based in the CCU.  You get the picture.  After about 4 days of this she finally threw up her arms and screamed she could not care for a patient down the hall from her in another unit. 

A few years after this at the same institution a pilot project looking at a tele-ICU was started at the same institution (with the same fellow who was now a staff attending) for managing critically ill patients at a small hospital several miles away who were without full-time critical care specialist support.  At the time this was not new.  Tele-ICUs had been established with one group covering a hospital across country.  Within a short amount of time this group showed decreased morbidity and mortality, they felt in response to full-time 24/7 monitoring by a trained intensivist from a control module and precise documentation of what was ordered by whom, when and what changes were made to medications and ventilator settings.  Ultimately, the project failed at my institution for the usual reasons – lack of clinical champion, poor IT support and hiring board certified specialists at the other hospital as the administration was under pressure to do so. 

A recent discussion in my current practice reminded me of this experience.  A group of pulmonologists, anesthesiologists and cardiologists were discussing the value of the stethoscope in clinical practice.  What is the sensitivity of the stethoscope for picking up an S4 or small pericardial effusion?  They can now get multi-color 4D echocardiograms rapidly with much greater accuracy.  How many medical students and residents can actually do adequate eye exams with their ophthalmoscopes?  Yet, for head and neck examination you will see PERRLA. EOMI. Nl disc reported and cut and pasted over and over in the EMR.

The Swan-Ganz catheter has been around for decades and its use is still debated in its efficacy in clinical use through so-called evidence-based medicine forums looking at the pros and cons of a test or technology. It is used to provide right heart diagnostic information, hemodynamic pressures, cardiac output and others.  If you look at the evidence, it does not decrease morbidity, mortality or prevent complications.  Yet, it is regarded as "standard of care" and who is going to deviate from that?  The other reason I think is that it provides measures which could not normally be done in caring for a patient, the benefit may still outweigh the risks of placing the catheter or not placing it at all.  It is the tool and test that is currently available. 

Of course all of this leads to more numbers and data in the chart to filter through which may be of minimal importance.  But what are you going to do?  Rely on a rudimentary stethoscope exam?

Category: Electronic Medical Records

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