Why Healthcare Documentation is So Bad

Care Venn Diagram CropHeath care documentation is done for three reasons.

1) Health care delivery (that’s the obvious one)

2) Regulatory compliance (checking all the boxes our government and payers think are important)

3) Malpractice avoidance (no one wants to get sued)

These three categories actually apply to every task we do in healthcare, but let’s confine this discussion to documentation.

Note in the accompanying figure, our three basic healthcare work requirements fit logically into a venn diagram. Much of what we do serves only one or two of the three driving purposes. In an ideal world, we work in the center of the diagram where all three converge. Unfortunately that “sweet spot” is pretty small, especially when it comes to documentation.

If all clinicians needed to do with our documentation was practice medicine (#1 above, blue in the attached Venn diagram), our notes would be more logical and much less bloated. Laundry lists of irrelevant and inaccurate diagnoses would not populate into every note. Copy and paste would occur a lot less often, and likely could be limited to appropriate uses such as carrying over past medical history (which should always be copy and pasted after verification to reduce errors). Only relevant physical exam findings would be reported, so these would not be lost in a sea of normals. Useful information that is not valued externally, such as personal touches – i.e. patient’s wedding anniversaries, achievements of their children, would have it’s own optimized workflow.

Regulatory compliance and malpractice protection, the #2 and #3 health care documentation purposes above, are responsible for the large majority of the drivel that shows up in our notes. Believe me, we doctors would all love to confine our work to health care delivery, but external forces box us into this uncomfortable place, and this creates junk documentation.

The result of trying to serve all of these missions results in the mess we have today. Healthcare IT expert Fred Trotter says that working with EHR is “like having a conversation with a habitual liar who has a speech impediment.”Care Venn Diagram EHR Crop

As I’ve diagrammed here, EHR serves all three basic functions, but not to equal degrees. EHR is designed for and sold to hospital administrators. Their first priority is business related – i.e. making sure the system runs efficiently and within the law. They work in the peach (Regulatory Compliance) circle.  After the Federal Government stepped in with EHR incentives, Meaningful Use requirements created a set of requirements for the EHR companies that are about 90% peach-colored as well.

After satisfying the needs of administrators and the government, EHR vendors allot remaining resources to serving working clinicians seeing patients, as well as the patients themselves. This results in the lesser segment of EHR devoted to care delivery represented in blue.

Malpractice protection, the green circle, is a critical area of alignment for both the administrators and clinicians. EHR systems provide some degree of protection via completeness and automation, but also introduce new risks.

Since working clinicians don’t make purchasing decisions, what is an EHR vendor’s motivation to optimize the systems for care delivery? Note, also, that the enormous cost of each system coupled with a lack of easy data portability effectively locks in a healthcare system to their EHR. Nowadays, most physicians are employees of their hospitals and lack sufficient leverage to effect an expensive change, even if such a clinician-friendly EHR system were available.

EHR activities fundamentally service the task of Regulatory Compliance (the peach circle) as their primary mission. This satisfies both the hospital administrators and the government. Because all parties have limited resources, the contribution to the Health Care Delivery circle suffers. Both hospitals and clinicians are interested in Malpractice Protection, so the green circle is served at of mutual self interest, although EHR workflow only tangentially addresses this need.

Clinicians need mechanisms to streamline documentation so they can spend time with patients instead of in front of computer screens. Ironically, many of the efficiencies built into EHR to give clinician more time with their patients have become targets of disapproval for our regulators and critics. I find it frustrating when I hear pundits and government officials rally against copy/paste and templates (such as normal physical exam findings). Most of these critics have no perspective on running a busy clinic or inpatient service. It would be impossible to do our jobs without some degree of automation. Do you think the legal profession would consider eliminating templates and copy/paste? Do you think contracts and wills are written freehand each time? Ridiculous.

Good clinicians need to fight external forces to protect their ability to care for their patients. That means we need to devote the large bulk of our time and thoughts to working in the blue circle of healthcare delivery. That’s where our mission is served. The other two circles? We should click/copy/paste/dictate/template only what is necessary to prevent us from being sued, sanctioned, denied payment, or accused of poor quality. If we can do that efficiently, we can get back to taking care of our patients. One casualty of this appropriate triage is ugly documentation.

Folks need to stop confusing healthcare documentation with health care delivery. Those who grade and pay us give far too much weight to the former. Those actually taking care of patients know where to set their priorities.

Edward J. Schloss MD

Adapted from my comments on EMR & EHR Forum post EHRs Don’t Make Errors, People Do.

Addendum 8/16/15: In response to a comment from Michael Katz MD @MGKatz036 discussing role of EHR in upcoding and other greed and fraud issues, I issued a lengthy comment/reply. Because it extends well my arguments above, I’ll include these as an addendum to the original post for better accessibility.

Mike, I’ve heard the concern that EHR causes fraud and increased cost charge many times. So much to say, but I’ll try to be brief

– E&M billing is already stacked against us. Leaving one irrelevant bullet point off the ROS list or physical exam can cause dramatic devaluation of an encounter. This is a playground for RAC audits and doctors live under that threat continuously. The system is illogical and need for attention to silly details draws up away from our primary mission. The EHR levels the playing field here. As I’ve said before, the dishonest MDs knew how to upcode dishonestly before EHR. Automation and reminders from EHR demystify the rules and lets honest doctors be fairly compensated. Do you have all the E&M rules memorized? Could your billing withstand an audit without the help of an EHR? If you were like many doctors, you’d just code level 3 and not take any chances. Ethical billing consultants (yes they exist) in the pre-EHR days found many doctors to be systematically undercoding because they didn’t want or know how to play the E&M game. If office charges go up after EHR, that may be entirely appropriate.

– How much free care is delivered now BECAUSE we have an EHR? I just spent 30 min on the phone doing two very complex patient evaluations involving EHR and remote pacemaker review. I did this at no charge. Without an EHR, this quality of care would be impossible without the paper chart. That means it won’t get done until tomorrow at the earliest, or I’d have to make do without the chart. In many cases we can prevent office and ER visits with this data access. Patient and system benefits, MD makes less money. It’s the right thing to do, so we do it.

– EHR charting is so painful, I often avoid the encounters altogether just so I don’t have to go through the misery of clicking through the documentation. The care gets delivered, I just don’t get paid. Lots of ways to do this, all ethical and appropriate. None violate our contracts. In the paper days, many of these would have been billed.

I decided not to include a circle on the venn diagram for unethical or inappropriate behavior. I have absolutely no doubt this exists and is a big problem. Nothing I say here denies this fact. This has been reported well and extensively by others.




ProPublica’s Surgeon Scorecard: Call for Peer Review

An Open Letter to Healthcare Outcomes Researchers, Journalists and Data Scientists

Thank you for taking to time to read this letter. I’d like to ask you to review some important new information.

Last week ProPublica published a major story and online data base they’ve termed Surgeon Scorecard. It has been promoted this as a tool for individuals to learn more about their surgeons before an operation. After looking at the Surgeon Scorecard data and methodology carefully, I’m left with serious reservations about its quality and applicability. I am requesting your help with an expert peer review.

In the project, ProPublica evaluated eight common elective surgical procedures using previously unreleased data from Medicare. Their source of information was administrative data from billing submissions.  Individual surgeons were rated based on readmissions and mortality. No chart level clinical data was analyzed for the dataset. Each surgeon was assigned a visual ranking based on their performance with a grade that falls into low (green), medium (yellow), or high (red) “adjusted rate of complications” with confidence intervals superimposed. My own work as a cardiac electrophysiologist (i.e. heart rhythm, pacemakers, and defibrillators) is not represented in this data. If you haven’t seen the database, take a look – enter a hospital or doctor you know and note the results.

Prior to the release of the database, ProPublica promoted the project with a video:

It’s worth a watch, as it may reflect the tone and purpose of their mission. There have been some negative reactions to this piece, and a lead reporter for the project has acknowledged this criticism.

This was a big undertaking, as you’ll see when you review. These physician scorecards could have major impact on the medical community, particularly if ProPublica expands their investigations beyond their currently narrow scope. For a journalist generated project, there is some pretty heavy science involved, particularly when it comes to the methodology of the database. The background was published in a separate white paper with appendices. They indicate that they consulted with experts, many unnamed on background, to analyze and format their data.

Upon release, there has been vigorous debate about the methodology of their project, particularly on twitter. If you search the stream of the reporters @marshall_allen and @olgapierce and the hashtag #SurgeonScorecard, you’ll find many of the arguments and their responses. Vocal critics include @JohnTuckerPhD, @skepticalscalpel, @justinmclachlan and @daviesbj. Numerous blog posts have outlined these criticisms and I’ll link to several that are worth reading:

ProPublica’s #SurgeonScorecard Should be Retracted from former journalist Justin McLachlan

ProPublica’s Surgeon Score Card: Clickbait? Or Serious Data? from urologist Benjamin Davies MD

The Problem with ProPublica’s Surgeon Scorecards from transplant surgeon Ewen Harrison

The Surgeon Scorecard is Here! (It’s Just Not Meaningful) from cardiologist Rocky Bilhartz MD MBA

After Transparency: Morbidity Hunter MD joins Cherry Picker MD from radiologist Saurabh Jha MD

The Surgeon Scorecard: Much Ado About Literally Nothing from general surgeon Jeffrey Parks MD

Here are a few high impact tweets addressing the statistical methods:

I realize there’s lot here to digest. Let me take a moment to summarize some major points.

– Responsible doctors agree that increasing transparency is appropriate. One of the major MD blog critics above actually wrote a book on healthcare transparency. We do not object to responsible, accurate reporting of physician performance. We recognize that it is very difficult to assess the quality of a doctor and this needs to be fixed. I have promoted my own idea of direct physician supervision. The folks criticizing this project value patient safety, and are not afraid to criticize doctors when appropriate. We are all seeking the same goals.

– Surgeon Scorecard looks at elective, low risk inpatient procedures and uses purely administrative data to score the surgeons. Only mortality and readmissions are measured. No patient level chart data is reviewed. Actual peri-operative complications and procedural success are not systematically measured. Many clinicians, including myself, have noted inaccuracies in administrative data (which is compiled without MD oversight). I think most clinicians would agree that without direct review of clinical data, it is difficult to accurately judge another doctor’s performance. To their credit, the reporters openly acknowledge these limitations.

– ProPublica applied a clinical risk-adjustment to the data. However, this co-morbidity “Heath Score” did not independently predict outcomes (Item 2.5 on page 11 of their method paper). Their model did not show an increase of deaths or readmissions in the patients determined to be sickest pre-op. This makes me wonder about the validity of their risk adjustment. If pre-op risk is not accurately assessed, the doctors that take on the most difficult cases will be unfairly penalized. Dr. Jha’s parable of Cherry Picker MD vs. Morbidity Hunter MD (linked above) speaks directly to this issue. OB/Gynecologist Dr. Jen Gunter also covers this concern well on her blog. If doctors are reluctant to take on difficult cases for fear of scorecards, needy patients could go undertreated.

– Individual surgeon data is presented with visual red/yellow/green rankings and confidence intervals. In ProPublica’s words, “A high adjusted complication rate indicates that a surgeon’s patients suffered harm more often than his or her peers.” Neither this explanatory document nor the scorecard app discusses the importance of confidence intervals in data reporting (this question is only addressed in a separate FAQ document). A surgeon may have his “dot” in the red, but have confidence intervals that suggest that he may actually be a high performer. I and others wonder if consumers will be able to interpret this complex data without a more up-front discussion by the reporters. There is no visual indication of P=non-significant for surgeons whose CI’s cross into low or medium risk. In a twitter exchange, journalist Reed Miller likened this to reporting a baseball batting average leaderboard without a minimum number of at bats. Scientist John Alan Tucker PhD covers this limitation well in his tweets.

– Procedure numbers for many of the surgeons are low, thus making the risk analysis difficult to interpret. Still these doctors are “graded.” In at least one case, a doctor with zero complications was ranked in the yellow zone (as criticized by cardiology outcomes researcher Mintu Turakhia MD in his tweet cited earlier).

– Many of the outcomes tracked are entirely out of the surgeon’s control, and may better reflect non-surgeon factors such as patient post-op adherence and emergency department staff actions.

– The statistical methods are complex, and there was no independent peer review. ProPublica acknowledges the work of doctors and scientists, many unnamed, in the review of their methodology, but editorial control was entirely in ProPublica’s hands.

– There is no prospective validation that these scorecards predict surgeon performance.

– There does not appear to be a mechanism for physician verification of his or her individual report.

– ProPublica’s promotional video is difficult to describe as anything less than sensational and fear-mongering. It is far out of place with the otherwise professional tone of this project. If you haven’t watched it yet, please do so now and tell me I’m wrong.

To their credit, ProPublica has bravely taken on a critically important mission that was certain to ruffle some feathers. They have done an enormous amount of work to create this database, and their presentation is beautiful. I have been a vocal fan of ProPublica’s work. I have also been both a quoted and background source for their reporters (although not on this project).

Some have argued that it was important to get this data out for public review, despite it’s limitations. I respectfully disagree. I subscribe to the belief that bad data is worse than no data. Certainly the scientific literature is replete with examples that prove this correct.

So is Surgeon Scorecard bad data? Strong words, but I say yes. This analysis was a great idea, but it fails to deliver on its goals. The data and methodology both have significant flaws. I say that from the perspective of a working clinician and clinical researcher with over 20 years experience, but I’d like to see a higher level of review. This project is as much science as it is journalism.  Surgeon Scorecard should be peer reviewed and critically discussed as would any scientific outcomes study. As I suggested to ProPublica, we need to kick the tires.

This is why I’m calling on experts in healthcare outcomes, data science and journalism to review Surgeon Scorecard on methodological grounds to determine its validity, interpretability and appropriate application. This needs to be evaluated thoroughly, and at the highest level of expertise.  I hope you will be willing to take a close look and let us know what you think. ProPublica has invited expert commentary by email at scorecard@ProPublica.org. Please submit your comments there, and leave me a copy in the comments section of this post.

Thank you,


Edward J. Schloss MD
Medical Director, Cardiac Electrophysiology
The Christ Hospital
Cincinnati, OH

EHR Review Folders – Saving Trees, Improving Care

I'm pretty sure we generate as much or more paper documents on EHR as we did in the paper charts days.

I’m pretty sure we generate as many or more paper documents on EHR as we did in the paper chart days.

On Twitter I’ve shared in many lively discussions about the struggles we have caring for individual patients on EHR systems that aren’t optimized for that purpose. Many better and more prolific writers have done a wonderful job outlining the frustration we front line clinicians face on a daily basis. Still it seems our voices have a hard time being heard.

I really don’t think EHRs really don’t have to be so difficult. Simple changes could radically change the ease of care delivery if the folks designing and implementing these systems prioritized the needs of the end users. Unfortunately, the bulk of development work these days seems to be aimed at satisfying government Meaningful Use requirements and optimizing systems for charge capture and quality metrics. Clearly EHR vendors have their hands full serving their two primary masters – the US government and hospital administrators – and the needs of those seeing actual patients are lost in the shuffle.

A couple of years ago, I hosted a couple of developers from Epic EHR for a day in my office seeing patients. We talked about a lot, but in the end I said I’d put one wish on the top of my list. I called this EHR Review Folders. Here’s a discussion of these concept, adapted from an email that outlines this simple request:

Thank you for your interest in the idea of “review folders.”  This is an old idea or mine, and I still think a good one.  I discussed this with our Epic site visitors, so I’ll include them in my email.  Let me try to describe my idea so we can try to get this promoted and (I hope) implemented

When we physicians see a patient in a new encounter or as a return after a period of time, there is a subset of the medical record that is highly relevant to us.  Most of this is predictable. We need any recent office notes from the referring MD, we need the most recent diagnostic tests.  We might wish to have the history and physical and discharge summary from any recent hospitalizations.  Every doctor has his or her own needs, but the basics are the same for all.  

In my office, our medical assistant does a chart prep prior to each scheduled visit.  She will comb through the EHR to find these relevant records, print them, and collate them into a packet that is then placed on my desk.  Since we may see 20-30 patients a day, this packet gets pretty thick and the assembly of the packet is pretty labor consuming.

It would be great if we could do away with this old process.  Unfortunately, the current EHR is not organized enough for us to quickly find relevant records on the fly.  Getting what we need can be a bit of a crap shoot because the relevant information is mixed with irrelevant information.  Only after we click on the record is it apparent whether we have what we need.  Even after finding all of the “good stuff,” there is no way to quickly go back to this record as it resides “hidden” with the other records.  In a busy office day, it is extremely challenging to click around the EHR to find all of this stuff.  Hard to find records, such as outside MD letters and other scanned documents are very easy to miss.  Most of us get frustrated, and may do an incomplete review on this basis.

My idea of a review folder would be to have a tab in the EHR in which all of the information relevant to the encounter could be collected during or prior to the encounter.  This tab would live in the patent’s EHR for as long as it is needed, and be visible to any who need it when they log in to the record.  I would envision having my MA sort records prior to the office visit by dragging and dropping the relevant records into this folder.  As I do my own prep, I will add and subtract records as well.  Some of this could be automated by having the folder collect specific types of records by date parameters or type.

A great analogy for what I envision is an Apple iTunes playlist.  On my iTunes, I can create a collection of songs into one folder that may be labeling something like “today’s run.”  I might drag and drop songs individually, or I might set up a “smart playlist” in which I specify parameters like “songs added after December 12, 2012” or “songs by the artist Ratatat.”  That list sorts what I need into one easy to find folder.

Uses for review folders could extend beyond what I’ve described.  Recently a interdepartmental complication review meeting was run for the first time in an EHR only format.  In front of a group of doctors and QA personnel, I struggled to find the relevant records in order to present a case.  Had these records been electronically sorted prior to the meeting and available on all parties Epic desktop, the meeting would have gone much better.

I find this idea conceptually logical, but I’m not sure I’ve done an adequate job describing.  I feel strongly that we could enhance patient care and save a lot of time and money if we could get this done.  I’d be more than happy to discuss further.

I’d love to hear other’s thoughts about EHR data organization. We go thorough an enormous amount of paper in my practice, purely to allow clinicians to review relevant data in an easy to access format. If some form of organized, intuitive digital data review is implemented, I could easily envision doing away with most or all of this printing. Going to a two screen solution with review data on a tablet and data entry on a bigger screen and keyboard is really an attractive option to me. Simple programming changes in our system could get us to this point. Does anyone have this sort of clinician data organization implemented in their EHR (Epic or other)? Would you find this useful? Would you help make it happen?


How Sure Can We Be About Optisure?

Edward J. Schloss, MD

On March 24, St. Jude Medical announced the global launch of the Optisure family of ICD leads. It’s been a while since a new ICD lead was launched, and I’m probably not the only one who was caught by surprise. I’d like to explore why this approval is important for the ICD community. First, a brief history of ICD leads from St. Jude.

St. Jude Medical developed its own line of ICD leads after it purchased the former ICD vendor Ventritex in 1996. The first-generation Riata lead, approved in 2001, was succeeded by the Riata ST line in 2006. These leads were distinguished, in part, by their thin diameter, permitting implantation through a 7 Fr introducer sheath. In that era, implanting physicians’ interest in a thin lead was very strong. Even the high-profile failure of the 7 Fr Medtronic Fidelis ICD lead didn’t seem to dampen that enthusiasm.

Both of St. Jude’s Riata lead families later developed problems. Reports of subacute perforation soon after implant in the Riata ST line arose in the late 2000s. A year or two later, the internal core structure of both the Riata and Riata ST leads was discovered to break down in 25% and 10%, respectively, of these leads, as evident on fluoroscopic evaluation — a process called externalization. This problem, along with noted increased electrical failures of this lead, prompted an FDA class I recall of both product lines in December 2011, in addition to intense scrutiny and discussion in the lay press, investor press, blogosphere, and academic literature.

By the time the Riata and Riata ST leads were recalled, St. Jude had already gotten approval and marketed the successors: Riata ST Optim and, later, the Durata lead. Both these leads shared design similarities with the Riata ST lead, but additional modifications were intended to prevent the failures that the predecessor lines had exhibited. To mitigate the perforation risk specifically, changes in the Durata lead were intended to minimize tip pressure to the myocardium. And both new leads had a new insulator wrapping around the silicon core from Riata ST. This Optim insulation, shown to be more resistant to abrasion, has apparently been successful at preventing the fluoroscopic externalization that had occurred with the earlier leads.

The failure of the Riata leads has been shown to be time-dependent, so the device community has expressed some concern about Durata’s future performance. In addition, FDA has continued to apply pressure, with a January 2013 warning letter about this lead, specifically noting problems detected during a California plant inspection. Early active registry studies of Durata have been highly favorable, but a limited number of Durata problems have been discussed in case reports. Noted ICD critic Dr. Robert Hauser has also reported on a series of Durata failures from the FDA MAUDE database.

The Durata and Riata ST may share some failure mechanisms. In particular, the Swerdlow case report revealed inside–out abrasion under the distal shocking coil, resulting in a short between that coil and the ring-electrode cable, and consequent oversensing. Swerdlow and the Hauser MAUDE study have suggested that a similar form of insulation failure at the proximal shocking electrode could result in failure to defibrillate. (Because Durata and Riata ST have essentially the same internal design and materials at the level of the shocking coils, it is possible that this failure mechanism will occur with the newer leads.)

Moreover, Swerdlow found evidence of disruption of the Optim layer, which he hypothesized was due to Optim degradation, possibly related to hydrolysis of the polymer and cyclical stresses during the 4 years of lead service. The long-term biostability of Optim is critical, because without the Optim layer, the Durata leads are quite similar to Riata ST.

St. Jude has staunchly defended Durata, citing the favorable active registry data and additional testing in a large bibliography on its website. The company’s independent engineering analysis concluded that Swerdlow’s lead was damaged externally as a result of the extraction tools, not Optim degradation (counter to Swerdlow’s assertion).

St. Jude released Optisure this week, its first new ICD lead line since Durata. The product literature describes Optisure as “providing an additional system enhancement for addressing lead complications and improving system reliability.” The company says the slightly thicker 8 Fr lead is “for physicians who prefer a larger lead diameter.”

According to St. Jude, Optisure is built on the basic design of Durata with these additional modifications:
• 8 Fr lead body
• additional Optim insulation at the proximal end of the lead
• new layer of Optim insulation under the SVC shocking coil

FDA filings show Optisure was submitted for approval as a PMA (pre-market approval) supplement on 10/24/12 and approved for release on 02/21/14. The filing links back to the original PMA for the Ventritex TVL lead issued in 1996. It does not appear that a human clinical trial was performed, as is common in PMA supplement approvals.

I’m happy that ICD companies continue to pursue process improvement. If we ever reach the point when we think we have a lead that is “good enough,” that will be really unfortunate. I’ve continued to have some concerns about Durata. ICD lead failures in the Riata lines have not become evident until 4 years of use, and we are only recently accumulating large numbers of Durata leads that have been implanted that long. Fortunately, Optisure’s design attempts to directly address two of the feared possible failure mechanisms of the Durata lead.

First, the increased Optim thickness in the proximal lead is likely to diminish the can/lead abrasion in the pocket, and perhaps in areas of cyclical stress. I find it really ironic and satisfying to read St. Jude promoting Optisure “for physicians who prefer a larger lead diameter.” Back in 2010, when I criticized thin ICD leads in an HRS debate, I had a hard time getting people to agree with me. Now, going thicker is a marketing strategy. Times really have changed.

Second, the Optim layer under the proximal shocking coil should help to prevent internal shorts that could cause lead failure. This type of short, if it involves the distal high voltage cable, is especially worrisome, as it may manifest only at the time of clinical or induced ventricular fibrillation. I fear that proximal coil HV shorting may be responsible for many of the Riata and Durata lead failures and deaths documented in MAUDE database entries, such as those published by Hauser (as well as this more recent report). Having a layer of Optim between the silicone core and the SVC shocking coil should help to prevent this shorting, just as it has prevented externalization. Unfortunately, this mitigation will not change the likelihood of shorting under the RV coil (as in Swerdlow’s case) but should help overall lead reliability. St. Jude seems to feel the same way, citing Optisure’s design as an “enhancement for addressing lead complications and improving system reliability.”

Getting a pacemaker or ICD lead designed, approved, and built is an enormous undertaking. The process has only become more difficult because of increasing regulatory barriers. The formerly common process of PMA supplement approval has come under greater scrutiny. ICD and LV leads that formerly might have been approved under PMA supplement now require large U.S. trials. The trials’ costs, coupled with the fear of another Fidelis or Riata debacle, appear to have stifled lead innovation. Given the development of two new leadless pacemakers (now being implanted in Europe) and the U.S.-approved subcutaneous ICD, we may be at the beginning of the end of the era of transvenous cardiac leads.

I have to agree with Zheng and Redberg that the PMA supplement process for medical device approval is problematic. The fact that leads from Riata to Optisure were approved on the basis of a dissimilar lead developed by a different company nearly 20 years ago should be ample evidence of this argument. Should Riata leads have gone through a clinical trial? Answering yes may seem logical. The unfortunate reality, however, is that no pre-market clinical trial would have picked up this lead’s late and novel failure mechanism. Even today, I would argue that careful industry engineering and close post-market scrutiny (including FDA-mandated registries) are doing far more to help our ICD patients than any pre-market trial ever could.

Nevertheless, it is critical to improve existing products, especially ICD leads. Most of us agree these are the “weak link in the chain.” I fear that a more highly regulated environment is having the paradoxically adverse effect of forcing us to settle with what we already have. That’s why I tweeted on March 24 that the quick approval of Optisure “both surprises and pleases me.” I wonder if this lead would even have been developed if it had been forced through a long, expensive clinical trial. Would that outcome have been a good thing?

Lessons Learned

September 10, 2013

Although I only started this blog last week, I’ve been active in online and social media for a couple of years. Today I’d like to repost a piece of mine that was originally published in the February 2013 edition of EP Lab Digest .

EP Lab Digest is one of those large format specialty magazines that get sent free to doctors’ mailboxes and hospital labs. Although many call these “throw-away journals,” EP Lab Digest is one that I read and keep.

Look for a Part II of this post in EP Lab Digest next month.

Lessons Learned in 18 Years of Device Implant and Follow Up

Over the years that we practice medicine, all doctors build up a mental list of tips or “pearls.” These are pointers, typically see in journal articles or books, that color the way we practice. Many of these tips were passed down during our training. Some we learn from our colleagues. Still others are original creations. As a private practice (and now hospital employed) electrophysiologist, I infrequently have the opportunity to share my tips with other physicians. When EP Lab Digest offered me the opportunity to write an article for this issue, I thought I’d brainstorm a list of these “lessons learned” with a focus on my passion of cardiac device implantation and follow up.

I hope you find these tips informative and at times provocative. Forgive me if some of this is too obvious. I welcome any input from the readers. Please feel free to comment or contact me at my twitter ID @EJSMD. I look forward to hearing your feedback.

  • Your unswerving mission as a doctor should be to make sure every patient you touch gets high quality care. This may have little to do with the metrics with which others judge you.
  • When a patient gets to 90 years of age, they get to make all the rules. A doctor’s job at this point is to do as little as possible.
  • Newer isn’t always better. Adopt new pacer and ICD technology gradually. It usually takes years in the marketplace before we know if a product is good or bad.
  • Pulling the left ventricular lead sheath is similar to taking a golf swing. It demands your full attention, and everyone in the room should hold still and stay quiet until it’s done.
  • Don’t ever forget how unnatural it seems to our patients to have a big hunk of metal implanted into their body.
  • Treat your reps with respect, but expect excellence. They are an important part of your care team.
  • If you haven’t discussed the option of ICD downgrade or abandonment with your elderly patients prior to generator replacement, shame on you.
  • When upgrading a pacer to an ICD, don’t be afraid to reuse or preserve the original RV pacing lead. It’s probably a better lead than the one you just put in.
  • Choose which vendor you work with in a principled manner. Consider product, price, support and value added service in each device implant decision.
  • It is (almost) never appropriate to get upset at a nurse.
  • Strive for a shallow angle of entry when obtaining venous access (this creates less flexion stress on the lead).
  • A left ventricular lead on the septum or in the apex with a good threshold is usually worse than no lead at all.
  • There aren’t too many CRT super-responders with RBBB.
  • Seeing sternal wires during a device implant is a good thing.
  • DF-4 ICD technology takes about 15 seconds off an ICD implant and adds a whole new set of potential problems.
  • Work hard to keep your hospital out of restrictive contracts, and don’t use any device model or make 100% of the time.
  • It is possible to have too much lead slack (Think St. Jude Riata)
  • Make your device pocket just above the facial layer, not within the subcutaneous fat.
  • Pay attention to the quality, timing and consistency of your pacer/ICD lead electrograms throughout the implant. We find it very helpful to display these continuously on our EP recording system right below the surface ECG.
  • It’s OK to work fast. Just know when it’s time to slow down.
  • Empiric VT zones in primary prevention ICDs are almost always a bad idea (thank you MADIT-RIT for proving this) [Note: PainFree SST trial, which I presented at HRS and EUROPACE 2013, showed safety of empiric VT Zones]
  • An ICD shock hurts, but it’s not as bad as being kicked by a horse (according to one of my veterinarian patients)
  • Don’t hold hard onto dogma without proof. Recall the DAVID trial was designed to show the benefits of dual chamber pacing in ICD patients.
  • If you implant a pacer in 20 year old, remember that someone may have to care for those leads for 50 years.
  • Pay attention to the timing of the electrogram on your LV lead. Long Q-LV times (i.e. activation late in QRS complex) correlate with favorable outcomes.
  • Work hard to save your hospital money without compromising your patients’ care.
  • If you can get the left ventricular lead implanted in the time it takes to play “Rapper’s Delight,” it’s going to be a good day.
  • Never become dependent on one of your vendors.
  • Fewer leads on a device means fewer things can go wrong.
  • Make sure to keep your long-term patient’s device programming up to date with contemporary standards.
  • When it comes time for pulse generator replacement, make sure you’ve seen your patient often enough that they will still recognize you.
  • When the scrub tech/nurse switches off during your case, this may be a sign you’re taking too long.
  • If someone could grant me only one wish about CRT, it would be to eliminate the problem of diaphragmatic stimulation.
  • The most important attribute in an ICD or pacer lead is a long established track record of reliability.
  • When checking the LV threshold on a biventricular pacemaker, make sure not to be fooled by right ventricular capture from anodal stimulation.
  • A lot of time can be wasted looking for the perfect P wave.
  • I’ve never had a patient complain to me that their ICD lead is too thick.
  • If there’s one piece of tech I hope I never have to do without, it’s our Site-Rite ultrasound for axillary vein access.
  • Despite all of its legitimate flaws, it’s a really good thing we have amiodarone available for our patients.
  • Work hard – really hard – to make your patient’s like you. It will pay off later. Much of what we do about relationship building. That’s one way to keep you from being replaced by an iPhone app.
  • Always say please and thank you to your scrub tech or nurse. “Scalpel, please” is much more polite than what we see on TV.
  • The best way to predict the future is to look carefully at the past. Never neglect to perform a good chart review.
  • It’s appropriate to be friendly with device representatives. They should not, however, be your friends.
  • For single chamber pacer pulse generators, it’s rarely cost effective to use the top tier model.
  • Never walk into a patient’s room until you know their story well enough that you can interview them face-to-face. Keep you nose out of the chart as much as possible.
  • No patient needs a primary prevention ICD, any more than they need to wear a seatbelt. We are our patient’s doctors, not their parents. Counsel with honesty and respect.


CRT Super-Response and the Power of Twitter

CRT Super-Response and the Power of Twitter

An unusual example of super-response to biventricular pacing and a commentary about real time academic collaboration via social media.
August 30, 2013

  1. What follows is a two day exchange on twitter earlier this week.  What was intended as a quick unknown case for the heart failure device community turned into something a lot more interesting.  Below I’ve organized the twitter posts and responses in the order in which they occurred and then follow with a discussion.  The topic is very specific to the pacemaker/ICD community, but the implications are much more broad.  Stay with me.

    First up is a ECG and electrogram recording from a biventricular ICD case that demonstrated some unusual findings.  I posed the question “What is interesting about this tracing?”
  2. Does anybody with interest in biventricular pacing wanna guess why I think this tracing is unique? twitter.com/EJSMD/status/37…
  3. Shortly after my post, a few folks took the bait and @ replied with their thoughts.
  4. @EJSMD RBBB with RV-EGM coming first… could explain why pt responded? but I don’t know why “super”
  5. @EJSMD despite underlying RBBB, LV activation is late in QRS duration. hindawi.com/journals/crp/2…
  6. Jeff is one of my industry support folks.  He and I have talked about this topic a lot.  He’s really smart and got it right away.
  7. @jvober Jeff, you’re like the smart kid in the front row going “Ooh Ooh, call on me!!” Hang back, let the other kids have a chance. 🙂
  8. @EJSMD why do u Measure the RV – LV interval from onset of RV to peak of LV? Interval seems pretty long
  9. @PAC_Aware The interval measured is called the qLV: Onset of surface QRS to LV lead activation. The LV mark may be a little late.
  10. I offered a study citation for those interested.
  11. Those interested in my CRT tracing may wish to review this study on qLV measurements @PAC_Aware: eurheartj.oxfordjournals.org/content/early/…
  12. @PAC_Aware So do you see what is interesting about this particular tracing?
  13. Below comments reply to those from @tobymarkowitz.  As his account is locked, I am not able to add these to the Storify narrative.
  14. @tobymarkowitz Interesting. We have not systematically evaluated CRT withdrawal in super-responders, but our anecdotal exp. has been poor
  15. The next morning I posted an annotated form of the tracing with an explanation of what was going on that I found interesting.
  16. F/U to CRT case: Here’s a RBBB CHF pt with normalized EF after CRT. Note evidence of LB delay by QLV & old ECG: twitter.com/EJSMD/status/37…
  17. Answer to yesterday’s CRT case up on last tweet: @tobymarkowitz @PAC_Aware @jvober @glibaudio @amcj1 Thanks for you contributions!
  18. Follower @amcj1 found this intriguing and we then passed around a few ideas about these findings and their broader application.  This exchange got me really excited about the power of twitter as a tool for real time academic collaboration.
  19. @EJSMD thank you, it’s very interesting. I wonder if it’s the case to measure Q-LV in every RBBB with low EF to decide BiV implantation
    • @amcj1 BINGO! Sounds like a hypothesis we could test.
  20. @EJSMD I was thinking about that… which catheter though? EP-CS and you measure Q-LV on the lateral/posteroL dipoles? or use a LV catheter?
  21. @amcj1 Currently we use the LV lead. Years ago there was .014 guide wire with bare end that could record EGMs. Very thin EP cath maybe.
  22. @EJSMD using the LV lead is expensive (in Italy, at least) and not so easy to do (long & short sheaths, guidewire, possibly contrast…)
  23. @amcj1 Agree, LV lead should only be used if you are committed to using it anyway. Not good tool for deciding CRT vs. no CRT.
  24. @EJSMD do you think/know if LV on the CS catheter (body) is approximate/correlates with the one on the LV lead (branch)
  25. @amcj1 Not sure, but suspect you’d have to get into lateral branch to know if LV is late. I’ll take a look in future cases.
  26. @EJSMD I’ll check as well we use an EP catheter to engage CS, I’ll record it and compare to the final LV; theoretically, it’s base vs. mid..
  27. @EJSMD .. if you stay at the same level (I mean, posterior vs PL vs lateral).
  28. @EJSMD ok, I better stop to bother you – you intrigued me, though! 🙂
  29. @EJSMD I’ll keep you updated, if you like!
  30. @amcj1 Definitely. Look at QLV times in the main body of CS and validate w lat veins. May be easy way to predict CRT resp in RBBB/IVCD.
  31. Real time twitter collaboration w @amcj1 could lead to a new tool to predict CRT response in non-LBBB. How cool is that? I’ll post storify.
  32. Discussion:

    The case presented is an example of CRT super-response in a patient with right bundle branch block (RBBB).  Let’s talk about the specifics of this interesting case, and how Twitter might be harnessed as a tool for real-time academic collaboration.

    Much of what I present here is true EP weenie stuff and I doubt I’ll be able to make it interesting to all but hardcore device/CHF folks.  Hang with me, though, because there’s a important lesson in here.


    CRT super-response has been defined in the literature as a >20% improvement in EF (http://www.ncbi.nlm.nih.gov/pubmed/20382271) or residence in the top quartile of EFs seen in a study population getting CRT (http://content.onlinejacc.org/article.aspx?articleid=1208648).  For my purposes, I like to keep it simple and describe CRT super-response as normalization or near-normalization of LV function after placement of a biventricular pacemaker or ICD.
    Seeing a CRT super-responder is one of the great pleasures in my practice, and I suspect most EPs and CHF doctors who work in this arena would agree with me.  Having been involved in management of heart failure patients for years before CRT was developed, I still find it amazing that you can take someone so sick and make them so much better with comparatively little effort.
    Factors that favor CRT super-response in the previously cited studies include female sex, nonischemic cardiomyopathy, LBBB and wide (>150 msec) QRS interval.  In practice, that is what I’ve seen.  I bet I could host a big picnic with all the happy LBBB non-ischemics we’ve helped by getting their EF over 50%.  On the other hand, the RBBB population doesn’t do nearly as well.  This is reflected in the latest CRT guidelines (http://circ.ahajournals.org/content/126/14/1784.full.pdf html) which assign non-LBBB with QRS <150 to a class IIB indication.
    Intuitively it makes sense that RBBB patients would not do so well.  We believe the main mechanism of CRT to be relief of intraventricular dyssynchrony by pre-exciting a late activating LV wall.  RBBB patients need not have any left sided delay, so it makes sense that many won’t response to LV lateral wall pacing.  We know that some RBBB patients also have co-exiting left bundle delay, and perhaps these will be the patients that respond the best to CRT.
    In the lab at The Christ Hospital, we’ve been using QLV (onset of QRS on surface to LV activation) measurements to define late electrical activation during LV lead placement for years.  We hook up our leads to the EP recording system and display them under the ECG recording.  This allows to easily see what is late when we are picking pacing sites in the coronary veins.  We try to favor long QLV measurements when settling on the pacing site.  It turns out the maximizing QLV with LV lead placement correlates well with favorable long term response to CRT.  I first saw an abstract  on this response from Jag Singh at Mass General.  In the tweets above I cited similar work from Michael Gold and others in the SMART-AV trial (including my old Cleveland Clinic mentor Pat Tchou).
    I’ve been paying close attention to QLV measurements at all of our cases, so when the patient presented above came though the lab for a pulse generator replacement, I was really surprised by what we saw.  Here was a male ischemic RBBB patient who super-responded (EF went from 20% pre-implant to 50% on his most recent echo).  That alone is pretty unusual.  Moreover, when we measure QLV in RBBB patients, we rarely see the LV lateral wall activate very late.  This patient had really late activation of the LV with a QLV, measuring 106 msec or 62% of the total QRS.  This really looked more like a true LBBB patient to me.  When I pulled up the old ECG (shown in the answer slide), it made sense.  This patient presented first as a LBBB patient, but over the years has developed additional RB delay.  In effect the LBBB is hidden by the RBBB.  Certainly the left axis is a clue, that this would be going on, but when I look at QLV in RBBB/LAFB patients, they are still typically very short.
    I put this up on twitter as a fun challenge and to get some input from some of the smart EP folks who follow me.  I’ve enjoyed participating in the unknown cases in the blogosphere (particularly those from Dr. Wes (drwes.blogspot.com).  For such an obscure topic, I was thrilled that a few people took the time to respond.
    After the answer was posted @amcj1 and I traded a few tweets that I thought were really cool.  Bear in mind I have never met or spoken to @amcj1.  Frankly all I know is the he or she goes by CJ and works in Italy.  He or she thought it would be interesting to use this as a tool to predict CRT response in non-LBBB patients.  That was exactly my thought as I prepared the case presentation.  Would the presence of a long QLV be a good way to decide whether or not to place an LV lead in these borderline patients?  We both think that this would be worth exploring.  Over a few tweets CJ and I worked out what might be a practical way to explore this hypothesis.  Maybe getting a QLV from the main body of coronary sinus with an EP recording catheter would give us the information we need to decide whether to go on to commit to an LV lead.  We could get that data quickly and relatively cheaply.  Clearly much more work needs to be done, but I can see the germ of a valuable research study here.
    I’m certain social media has an untapped role in the advancement in science.   In the world of healthcare, we are really only scratching the surface of what is possible.  Imagine Twitter exchanges like we covered above on other difficult topics in medicine.  Through real time collaboration, we could harness the collective intelligence of the many to reach conclusions and create ideas that none of us could accomplish on our own.  No topic is too obscure if the reach of the media is broad.  Social media is democratic in the best sense of the word.  The best ideas will percolate to the top, independent of the usual barriers such as academic status or job title.
    Edward J. Schloss MD FACC FHRS
    Medical Director, Cardiac Electrophysiology
    The Christ Hospital
    Cincinnati, OH

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