When Rules Don’t Rule & Regulation Becomes Frustration

When my sister and I were young we wanted to see the movie Gremlins more than anything, but my parents were concerned it would be too scary for us. We must have been really persistent because they ended up screening the movie for us to make sure it was appropriate (and maybe to have an excuse to escape from a 6- and an 8-year-old for a few hours). They saw it and approved it with the stipulation that we’d see it as a family. If it got too scary we were to either cover our eyes and ears or we would all have to leave. And no individual popcorn and drinks. We were sharing the family combo – a bushel basket of popcorn accompanied by a 36 gallon pop – or nothing. Those were the rules we played by to go see the movie.

It was a good prelude to the movie which is also all about rules and what goes wrong when you break them. There were three rules to caring for the sweet, furry little Mogwai named Gizmo.

  1. Don’t get him wet.
  2. Don’t expose him to bright light.
  3. Don’t feed him after midnight.

Of course all these rules get broken and madness ensues. You’d have to guess that these rules were put into place after accidentally discovering what  happens if you feed a Mogwai after midnight (he’ll eat the sandwich along with your hand). The rules were meant to protect others because some unfortunate soul had already learned what Mogwai without rules do…they turn into Gremlins.

The rules started for a reason. There was a situation that needed controlling so rules were created. I truly believe that is how regulation in healthcare began, as something to help and protect patients, employees, and healthcare as a whole. Plus, if we all follow the same rules, we can be more standardized and deliver health care on a consistent level. Things may have changed over the years, we’ll get to that in a bit, but initially rules were created to give guidance.

Untitled designNot everyone agrees. Years ago I was having a discussion about Medicare rules that said the agency would no longer reimburse for hospital-acquired conditions like pressure ulcers.

The person I was discussing this with said she didn’t think we needed all these rules and regulations. That hospitals, executives and healthcare workers in general would do what was right. I pointed out that rates of central line infections had dropped dramatically since the rule was put in place. In New York, for example, central line infections had dropped to 735 in 2012 from 1,557 in 2008, so we likely weren’t doing everything right in the first place. “Maybe we keep getting these regulations because we keep doing things to deserve them,” I explained. That was met with silence. And I understand why.

As I said before, rules are often started with the best intentions (and yes, I do know that there are times when rules are made to financially benefit individuals or special interest groups, but that is a different issue). But then, just like with a Mogwai, someone goes and spills water on them or feeds them after midnight and our helpful rules become out-of-control monsters. The rules morph into things that cause frustration, bureaucracy and waste staff time and energy.

Like clinicians, Health IT and EMR professionals have their share of frustration with regulations. During the during HL7standards.com May 30 Tweet Chat, there was some thoughtful and interesting conversation about this topic. You can read the transcript here and as you’ll see Questions 3, “What improvements should be made to the certification process for #MeaningfulUse tech?” and 5,
“Would it be beneficial to separate caregivers’ EHR complaints from complaints on standards and certification?” spurred the debate.

Like clinical staff, HIT professionals also struggle with getting bogged down by rules. While the intent of the rules was often admirable, they’ve morphed into something than can make getting a job done more difficult.

As a clinician, I saw a lot of this during my time working in hospice admissions. Some issues were HIT related and some were not. On the top of my list of frustration with regulation was the DEA’s Controlled Substance Act. During my time at hospice, it was announced that to be in compliance with the act, nurses could no longer act as agents of physicians to relay schedule II medication orders to a pharmacy.

There were a lot of ins and outs to this law regarding telephone orders, written orders, etc., but basically, if a patient needed morphine (which the bulk of hospice patients do), I could not take a verbal order from a physician and call it to the pharmacy. The physician had to speak directly with the pharmacy to give the verbal order and follow up with a written order. Trying to get physicians on the phone to give hospice orders was tricky enough, sometimes I’d wait at least an hour, but to now have to tell them to either hold to do a three-way call with a pharmacist, or ask them to call the pharmacist themselves, made matters even more difficult.

The original law had good intentions at preventing diversion of these potent medications. The unintended consequences was more work for both physicians and nurses and a longer wait time for much needed medications.

There was also frustration with use of EMR during my hospice days. Many of the staff there couldn’t stand using EMR. It took at least two hours if not more to chart an admission. Part of this was because, in my opinion, we were using a system that was not designed to integrate with our workflow. Then there was the double and triple charting which we were told was needed to be in compliance with Medicare regulations. Why Medicare needs a PPS score listed in four different spots on a chart I don’t know. I think this explanation was meant to shift the focus of our annoyance to Medicare rules and away from the EMR. Maybe that was justifiable, but it didn’t improve the situation any.

And as pointed out in the chat, maybe some of these frustrations should have been seen not as issues with EMRs, but rather issues with regulations. However, regardless of  the source of the frustrations, they are still valid if the underlying issue prevents staff from getting their job done. When clinical staff voices concerns of the technology and the HIT staff can’t make changes because their hands are tied, clinicians aren’t simply going to be calmed because rules and regulations may be standing in the way of improvements, not the hardware, software or systems causing the bottleneck.

The bottom line is that rules need to be workable for all parties involved in Health IT. If they’re not, they’re wasting time, money and efficiency.

What frustrations have you run into as clinicians or HIT professionals? Have you found any productive ways to address these issues?

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Jennifer Thew, RN, MSJ

Jennifer Thew, RN, MSJ, is a registered nurse and journalist who has covered healthcare issues and how they relate to the nursing profession. She began her nursing career as a neuroscience nurse at Rush University Medical Center in Chicago and then transitioned to journalism after receiving a degree from Roosevelt University in Chicago. She has edited and written numerous articles on a wide range of nursing and healthcare topics like Accountable Care Organizations, evidence-based practice and telehealth.

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