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How I, A Doctor, Came To Build An EMR

My desire for integrating the power of technology with primary care started nearly two decades ago. It was then, when working as a family physician in a busy medical practice, that I began experimenting with typing my notes and using computers in front of my patients.

In 2001, I launched a new medical practice DocTalker, focusing on access of medical care to patients, and almost immediately I started searching in earnest for an EMR solution to fit my needs. However, I was not happy with the systems I looked into and tested and felt that they didn’t do what I needed them to. 

Some of my discontent came from the way my medical practice consults with patients, which is primarily via telephones and emails and house calls (in addition to the common office visit). Because of our ability to offer telemedicine, we often treat patients when they’re not  in town, but rather traveling for business or taking a vacation. We therefore must interface with hundreds of different local labs, radiology groups, pharmacies, and specialists. Read more »

The Five Cornerstones Of 21st Century Medical Care

Eight years ago, the Institutes of Medicine published a paper entitled Crossing the Quality Chasm: A New Health System for the 21st Century, which envisioned the future medical practices. Many of the concepts discussed were adopted and endorsed in years to come by the American Academy of Family Practice, The American College of Physicians,  the American Medical Association, among others.

The five major innovations of care outlined by this study include:
1.    A communication-centered practice model,
2.    Information management,
3.    Technology replacing office staff,
4.    Reduced pricing and transparency in billing, and
5.    Removing external conflicts of interest between doctors/providers and patients.

Complete adoption of these innovative concepts can cut at least 30% of primary care costs while significantly improving patients’ quality of care, and further reduce overall health care costs by offering immediate and highly accessible care that avoids emergency room visits, enhances wellness, manages chronic illness and diagnoses disease early. These cost savings and quality improvements are enabled by utilization of advanced communications and information technology that replace much of office overhead and staff, and encourage patients to seek the most cost-effective and convenient care possible.  Many medical practices have adopted some of the recommendations, yet less than 1% have transitioned to complete and consistent adoption because they frankly have few financial incentives to do so.

These innovations are the cornerstones of retooling our broken healthcare system, and in turn can pave the way to “fixing” many of the issues plaguing this system. The five cornerstones provide for what so many Americans are clamoring for yet are unable to find: continuous access to a medical provider team thus enhancing patient access, control, and convenience of care; increasing the quality and speed of treatment; reducing the cost of care; creating transparency in pricing; and removing external parties that create conflicts of interest between doctor and patient and often interfere with providing quality and speed of care to patients.

I’ve built my own primary care practice on these five concepts, and while all can significantly lower costs while vastly improving the patient experience,  I’d like to take a look at the concept I find to play a pivotal role: a communication-centered practice model.

A Communication-Centered Practice Model
Twenty-first century, day-to-day-primary care starts with the primary care provider being the first in line to answer a patient’s phone call or email. During this call or email, the provider reviews a patient’s history, and bearing in mind that the provider already knows has a professional relationship with the patient, then can make appropriate decisions.  At least 55% of the time, the patient’s situation does not require an office visit, however instead involves going straight to the pharmacy for medications, going to labs for tests, getting an x-ray, or recommending a referral.   In this model of practice, the doctor spends at least half the time of the time answering phones and emails, thereby providing immediate access and convenience to the patient.

If either the clinician or the patient believes there is a need for an office visit, the visit is arranged immediately.  Patients can talk to their medical expert or an on-call member of the medical team 24/7. This instantaneous access can result in patients having most of their day-to-day  issues addressed within 10 minutes of reaching the practitioner, and can expect care from their personal provider from home, work or anywhere in the U.S.

As mentioned above, over 50% of medical issues can be addressed by telemedicine, specifically by phone or email, as long as a patient-doctor relationship exists. This results in people being healthier and on the road to recovery much faster, thus not taking time off from work.   Office hours are flexible and can be arranged day or night and any day of the week including weekends.

The importance, barriers to adoption, and the unexamined assumptions as to why 97% of all  medical care currently occurs in a medical office and nowhere else has been reviewed in several of our prior postings:

Are Face-to-Face Office Visits Really Required to Provide the Highest Quality Care?
In Defense of Remote Access Medical Visits
The Commonplace Tool That Can Revolutionize Health Care
Telemedicine Care: A Malpractice Risk? Au Contraire …
Telemedicine Checks In On Chronic Health Care Problems

In the future, I plan on taking a look at the additional four cornerstones that need to have traction if the Obama administration hopes to restore vitality to the primary care system.

Until next time, I remain yours in primary care,

Alan Dappen, MD

Silence: The Value of Listening

Between what is said and what is not, the truth lies in waiting. Palpate the silence. Hear the double meaning. Smell the hesitation. See the nostrils flare. Watch the direction of the gaze. Feel the tension.

The truth vibrates in myriad ways. It is deep, below the surface. Frank Herbert’s novel Dune illustrates the concept with fascinating fiction. Imagine a people –the Bene Gesserit —  genetically bred and trained as seers into the unconsciousness, sensors of the truth, like breathing lie detectors. Little did I know that such truth seers are not just a part of fiction, and although a rarity, live and walk amongst us.

I have met such a seer. Towards the end of my residency training, a gifted psychologist was assigned to follow me as a routine part of our training. I’d become competent and efficient in administering my craft. “My doctoring will impress her,” I thought with some pomp.

Right before the first person we saw, she told me, “Pretend I’m not in the room.”  Then, for the duration of the morning, she silently observed the patients I saw and my interaction all while in the back of the room.

After seeing a few patients, we’d break and talk. The patients I saw, I felt, were representative of standard primary care issues: Joe forgets to take his medication. Susan can’t quit smoking. Elaine has unexplained abdominal pain. My medical paradigm explained that Joe, like most people,  can’t comply taking continuous medications.  Susan is addicted, not interested in quitting smoking until she’s good and ready. Elaine’s pelvic pain is mysterious but not worrisome.

I’m stunned when, after my medical analysis, the psychologist paused, emitting a rueful smile. She sighed knowingly and responded, “Actually, Joe is angry at his wife and defies her by refusing to comply. Susan has unresolved issues with her father who’s probably an alcoholic. Elaine’s pain suggests sexual molestation.”

“Give me a break!” cried a voice from inside of me. And as the days rolled along there were other voices too.  “I am a family doctor. This is not medicine! I don’t have time for this! Just what you’d expect from a psychologist; too much Freud!”

As the weeks turned, I reluctantly see her hit nail after nail on the head. She saw complex patterns in people’s behaviors and complaints that I’m too blind, and too unwilling, to see.

With this new, almost astonishing, dimension to medicine, I see, for the first time, art, compassion, insight, and intuition as equal partners to the formulas of science. I slowly wonder what it truly means to be called “a doctor,” when so much is missed in the science of “performance.”  I am captivated, begging to know: How does she see? Can I learn? Is she gifted or crazy?

We are in the final days of my tutelage when we meet an enraged Sharon, in follow-up from the emergency room after a miscarriage. She didn’t know she was pregnant, began to bleed, and ended-up in the ER. She was pushed into a back room, left alone for a long time, bleeding heavily. She felt abandoned, angry, and humiliated. The ER attending staff, she insists to me, made her feel like a “slut.” I listen and then promise to investigate and call her back.

In the post-patient meeting I explained to the Bene Gesserit (as I now secretly called my psychologist mentor), “Delays occurred in the ER’s treatment of Sharon and she was over reacting but never in danger.”

“Right about the danger,” the Bene Gesserit concedes, “Wrong about what happened. Sharon had an affair her husband found out about it through the miscarriage.”

Having been humbled too many times, my resistance drops. “What did I miss can you show me?” I beg.

“You sense her over-reaction, her anger, yet dismissed it. Something else fuels her rage. Close your eyes. Pretend to be having a miscarriage right now. I’ll coach you through it.”

“This will be tough.”  I think, “I am a man and can’t really miscarry and am sitting in the doctor’s lounge with plenty of colleagues enjoying this play acting.” I close my eyes and settle into a foreign reality. It doesn’t take long to be guided to bells ringing in my head. “I don’t feel like a slut.”

The Bene ignores me and continues, “The vibrations are always there if you tune your antenna to the right frequency. People are pools of water with surface and depth. Illness arises within a context. Ripples on the surface are the symptoms caused from objects thrown-in or vibrations from the past arising to the surface. To reveal this union between the physical and emotional bodies is a unique potential of a healer. “

Sharon’s husband visited my office three days later, chief complaint chest pain. The betrayal was written all through him and verified as forecasted by my mentor. Unnerved I began in earnest to train my own antenna as to reach my fullest possible potential as a healer, a potential only realized by committing the time to listen comprehensively, intuitively, respectfully needed to do so.

Medical care today is all about the quantitative: 10-minute office visits, performance-based measurements, and only the facts.  Medical problems are often not simple algebra formulas where the sum equals its parts. Many times healing requires the art of listening, intuition, trust,  insight, empathy, grace and even spirituality. It’s not neat, nor quantifiable, but many have journeyed through life enough to know it’s true. Even after all the science has spoken, the art hides itself in myriad ways, patiently waiting.

Until next week, I remain yours in primary care,

Alan Dappen, MD

How Primary Care Providers Can Help Women Hurdle The “Roadblocks” To Their Care

A report just released on, the website for the Obama Administration’s healthcare reform effort, is entitled Roadblocks To Healthcare: Why The Current Health Care System Does Not Work For Women, and cites that more than half of American women (52%) delay or avoid care because of cost, compared to 39% of men.

A video synopsis of the report, hosted by Kathleen Sebelius, the Secretary of Health and Human Services, states that women are being left behind when it comes to healthcare and that there are over 21 million uninsured women in the U.S.  Young women have much more difficulty finding affordable health insurance than do men and often pay higher premiums – sometimes one and a half times – those of a young man. These facts all add up to women not getting the care they need to stay healthy.

As a primary care provider (PCP) focusing on women’s health, the findings of the report don’t surprise me, not even a little. From my anecdotal studies of the number of women that I have seen over the years, the majority of women struggle to receive the care they need because they cannot afford it. What typically will happen is that these women delay, often for years, any type of check-up or preventive care because of costs. Instead, they wait until they are sick or are having issues, and then they are forced to find the money and the time to seek medical care.

I also have found another factor beyond price that is creating a barrier to healthcare for women,  and the word is “convenience.”  Many women cannot, or often will not, take the time to seek routine medical care when most doctor’s offices are open, which is nine to five. Frequently these women are working, albeit on jobs that offer them little or no healthcare coverage, and are loathe to take time off of work for a non-emergency medical issues. Women also have the lion’s share of childcare responsibility, and are more likely to put their children’s schedules and family needs well before theirs.

Primary care can be the first place to look for a solution in bringing affordable, convenient care to women so that there are no roadblocks to access. We strive to do just this at our practice. Our Well Women Clinics were spearheaded after much deliberation about cost and convenience.  We started last year and have found them to be a great success. For these clinics, we designated specific days during the month for routine well women check-ups. Hours for these check-ups are early morning through lunch one day and mid-afternoon through evening on another days. We offer the clinics two days each month on different days of the week, ideally making times available for each patient’s schedule, whether she is a current patient with us or a new one.

Although the biggest hurdle for women to getting the care may be cost, as the Obama Administration’s report cites, let us not forget the role that convenience in getting this care plays. Healthcare and wellness does not have a nine-to-five schedule. Likewise, most women’s roles beyond possibly those in a regular “office” job are not on such a regimented schedule; their roles as caretakers and mothers have round-the-clock demands. We need to work with women determine and then remove all of the roadblocks to accessing of care, starting first and foremost with cost, moving to convenience and then considering others that may exist.

Until next week, I remain yours in primary care,

Valerie Tinley, MSN, RNFA,  FNP-BC

Telemedicine Checks In On Chronic Health Care Problems

“OK,”   I can hear you say, “Enough about telemedicine. So what if you can prevent two-thirds of office visits by using the phones, or that it’s convenient for the patient and can start them on the road to recovery faster, or that it costs much less money than conducting an office visit, or that malpractice companies have accepted this delivery model.

I can see that you still side with the other non-believers in telemedicine, citing, “Telemedicine is no way to build relationship with patients. Problems abound with telemedicine: It’s too impersonal, patients could easily not be telling you the truth because you lose the “body language and facial expressions,” and it certainly can’t be useful for chronic illness. Maybe it’s good for the simple problems, but this has no place with complex or chronic medical care.”

I do, of course, have some rebuttals for you …

Let’s start with impersonal.  In today’s world, we let our friends and family communicate with us constantly through phones and email, and I’ve yet to see how this has destroyed the intimacy of our relationships. So why do Americans anxiously wait up to four days for a doctor’s appointment to get their problem or question resolved and waste at least four hours of a day to get to the office simply to wait for an unpredictable time for a predictable 10-15 minutes of the doctor’s time when so many issues can be resolved remotely by phone? Furthermore, try convincing someone with a urinary tract infection (UTI) or that needs a prescription refill that their long wait, suffering, and run through the primary care funnel were “good for the relationship.”  In fact, nothing is more personal that a doctor saying to their patients, “Here is my direct phone number, please call me anytime you need help.” Viewing telemedicine from this perspective determines that the “impersonal” concern is a ruse to protect doctor’s privacy at the expense of their patients.

What about the patient who is not truthful? Does a face-to-face visit make this less likely? In 30 years of work, several patients I know have not always been honest.  Many of these people were attractively dressed, well educated and for awhile, fooled me badly. I saw them all face to face too.  To this day, I have no idea what to look for when someone is trying to pull the wool over my eyes.

If people are going to hide the truth, they can do it in person just as well as over the phone.  When a doctor becomes suspicious about a patient’s truthfulness through a pattern of calls and behaviors, then a scheduled office visit may help.  However, forcing office visits based on a blanket rule of thumb of not trusting your patients means there is something fundamentally wrong with the doctor-patient relationship.

Lastly is the idea that chronic disease management isn’t appropriate through phones and email. Really? Let’s say you had diabetes, or hypertension, or high cholesterol, or cancer, or depression, just to name a few.  With one of these conditions, you will be in contact with your health professional a lot more than you are now. Not only is your life more complicated, but the doctor wants you to consume 10% of your life waiting to see him in person because it’s good for him. Instead, many of these visits can be conducted easily anytime through phone calls and email.

Here are some examples:

#1. A phone call: “Mr. Doe this is Dr Dappen. I see a calendar reminder that you’re due for labs to check your cholesterol and to make sure the statin drug we put you on is not causing problems.  I’ve faxed the order to the lab that is located close to you home, so stop by anytime in the next week and they’ll draw the blood. I should have the results in 24 hours after your visit to the lab, and we can review the report over the phone at that time and decide if we need to make any change.”

#2. An email from a patient:  “Dr. Dappen, I’ve been worrying about my blood pressure readings. Over the past 3 weeks, they’ve been running consistently higher. Not sure why and until recently the home readings were doing great. Attached is the spread sheet of readings. Look forward to your input.”

In fact, examples abound of how chronic disease management conducted via phones and email is more efficient, reduces costs, and improves outcomes; I’d invite any Doubting Thomas to visit the American Telemedicine Association for further inquiry.  An entire telemedicine industry is gearing up to manage chronic illnesses and most of the time it has nothing to do with patients visiting doctors’ offices.

When all is said and analyzed, the conclusion is really simple as to why the use of telemedicine is not more prevalent: no one wants to pay a doctor the market value for the time it takes to answer a phone and expedite an acute problem or manage a chronic health care problem.  No money means no mission. This means no phones, no email.  Don’t think about it.  See you in the office.  Why ruin 2400 years of tradition?

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