June 24th, 2009 by AlanDappenMD in Primary Care Wednesdays
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For 18 years, primary care providers steadily have been eclipsed by “specialists.” It is no longer rare to hear calls for these competent generalists to drive straight to the scrap heap in order to be refitted as procedural, money-making Humvees. What may be implied by this scenario is that primary care providers are selling out so as to allow nurse practitioners to be a more economical, efficient and smarter primary care provider. In fact, such ideas are not impossible if primary care doesn’t take control of their own destiny and invest in their own future. Technology will prove such a pivotal investment.
In my June 10 post, I discussed the five cornerstones of 21st century medical care as presented by a book published by the Institutes of Medicine entitled Crossing the Quality Chasm: A New Health Systems for the 21st Century. The first cornerstone presented a communication-centered medical practice and abandoned the traditional brick-and-mortar idea that “the answers to all medical questions must be delayed until the patient is seen in the office.” Rather than the doctor being the last person to know what’s happening to a patient, a communication-centered model puts doctors at the front of the office, answering phones, emails and internet-generated questions through the day, allowing the practitioner to be the first ones to know what’s happening with our patients. This model could eliminate up to 66% of today’s office visits while simultaneously improving speed of delivery of care, convenience, access, quality and reduce costs.
The second cornerstone that primary care needs to invest in and build is an advanced information management system, which still does not exist. An electronic medical record (EMR) that replaces a paper chart does not adequately explain the real potential of a tool that could transform the generalist.
Information in the communication-centered practice is managed differently than in traditional models. The health care provider, surrounded by phones and computers, is linked to a powerful network with electronic medical records, health information databases, sensitivity-specificity measurements, medical literature, and information about local facilities such as laboratories, pharmacies x-rays, and consultants and their costs, just to name a few linkages.
Imagine information no longer limited by what is in the doctor’s head, but rather, doctors who can access and find the answer to any medical question within seconds by having bookmarks that extend through an entire medical library, and searching for answers would be as easy as: The evidence based guidelines treatment for this problem is “click”… The differential diagnosis for night sweats is “click”… The medicines known to cause “weird smells” as a side effect are “click”… The cost of that test is “click”… The three labs closest to your home where I could fax the order are “click”…The sensitivity and specificity for this test or that symptom or that physical finding to be associated with lupus is “click”…The recommended treatment for this fracture is “click”…The three best articles for helping patients manage and educate themselves about their cholesterol are “click”… The telephone number to arrange setting up the test is, “click”… The facts and comparison for this medicine is… “click” The video link demonstrating the Canalith repositioning maneuvers is in your email box… “click.” Primary care providers help patients work through this information, discerning what is of utmost importance to their medical situation and issue. As it is said, “The role of the expert is to know what to ignore.”
Excellent primary health care requires continuous communication between doctors and patients so as to respond through the evolving and unpredictable twists and turns of illness and treatment . Doctors likewise need connection to the highest quality information and recording systems so as to actualize the science of best “healers”. The idea that doctors should always know the answer to a problem by using memory alone is as misguided as insisting mathematicians return to pencil and paper calculations to prove that they are “real” mathematicians. Despite the potential, primary health care has remained timid to challenge the unexamined assumptions behind the limits of Hippocrates medical practice. Were Hippocrates to return today I imagine him asking, “What have you done?”
Our patients need doctors to step up to the plate and go to bat for them. We as doctors need it too.
Until next week, I remain yours in primary care,
Alan Dappen, MD
June 22nd, 2009 by DrRob in Better Health Network
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I have heard a lot of talk about ownership of medical information. Bloggers like e-Patient Dave, and Robin are strong advocates for patient ownership of their information. To be truthful, I get nervous when I hear people saying they own something I have in my possession (and I’ve blogged about this). The charts in my office are mine, right? How can I create something and have it not be mine?
I carried this unease with me into the exam room recently. Thinking about the ownership of medical information, I opened a patient chart. The vital signs were already in, and I started in on the HPI (the patient’s story as to why they are there). I do this by asking questions: When did it start? How long did it last? What did it feel like? What did you take? Did you have other symptoms with this? How bad was it? Have you ever had this before?
Hmmm…. Whose information is this?
Then I went on to the review of systems. We have the patients circle symptoms on a laminated sheet and I discuss what they circled.
“You have some chest pain?”
“Well, it was a sharp pain that happened when I coughed. Is that bad? Could it be my heart?”
We then go into a discussion about chest pain and what to look for.
I put down the information the patient has given me and think a little more. The patient’s information?
Then I get frustrated. The past medical history hasn’t been updated recently, she’s been in the hospital and most of the information about this is not in the chart. The medication list is not accurate. The information about her family, lifestyle, and habits are incomplete and I don’t know when they were last updated. I sigh, then try to fill in the gaps as best as I can by asking her questions without betraying my lack of confidence in our record.
We have a meeting of our IT team after this, and I am thinking about this encounter. We are about to roll out a patient portal where patients will be able to log onto our website securely and fill out patient demographics, request refills, and get appointments.
“What information in the record would the patient be best to be in charge of?” I ask. By being “in charge” I mean that the patients would have actual control of this information and we would read it. I tell them about my experience and frustrations and we make the following list:
- Marital Status
- # Children
- Job/School info
- Home DM monitoring, weight, BP
- Address, phone, e-mail address
- Family history
Then I ask, “What information in the record could the patient contribute directly to?” By this I mean that they would see the information as it is in there and be able to suggest changes or additions, but would not be able to actually change themselves. Here’s what we came up with:
- Smoking, alcohol
- Medication List
- History of visits to other medical providers, consultant names, etc.
- Review of systems prior to visit
- Surgical history
We want to be able to assemble this information so that it is in a format that is readable to us and fits our needs, but the patient would have the ability to take this data information and perhaps download it to organize as they wish.
“So what information should they have access to?” I ask, referring to information they can see, download, and organize as they wish, but not add or subtract to. Here is that list:
- Upcoming tests needed (Colonoscopy, etc)
- Immunizations
- Lab results
- Visit schedule – past and present
- Previous vital signs
- Recommended schedule based on their diseases
- Problem list?
Finally, we discuss what is our own information that the patient only has access to if they request it. This is information that either will give them too much information (our thought process and remote concerns) or even things that we don’t want them to see (suspicions about truthfulness or worse). Here is this list:
- Perhaps the problem list – if it contains things like anxiety, suspected abuse, or private things the patient has told us.
- The HPI often has information that is potentially sensitive. People have to feel free to tell us things, and having that information be back in the face of the patient on the Internet (albeit a secure site) goes a bit too far. Who knows if a family member can access it? What about teens? It’s just too complicated.
- Part of the assessment and plan is often conjecture and reminders to ourselves to pay attention to things in the future. If a person has weight loss, we may keep cancer in the back of our minds. If a person is asking repeatedly for narcotics, we may write down suspicions that bear watching in the future. We have to have a place where we can put things down and know they are for our own eyes only.
The last list is the shortest. Yet the current state of things is that the entire chart falls into the last category. This not only leaves the patient in the dark, it makes it so we have to do a whole lot of unnecessary work that the patient would do much better at (and without costing us a dime).
I think this is the sweet spot. This is the way the medical record should be in the future. It should be a shared venture – not just between PCP and patient, but also including other providers. For care to truly move forward we have to dream about what it could be. Our office now has this as the vision for where we want to head. I know my patients will be thrilled, and I am pretty sure I’ll have a lot less frustration in the exam room.
*This blog post was originally published at Musings of a Distractible Mind*
June 5th, 2009 by Dr. Val Jones in Opinion
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Have you ever been ignored by someone who was texting or otherwise engaged in a digital conversation? Did you feel that the person was being rude and unresponsive to you? If your answer to both of these questions is “yes” then you will understand the real reason why some doctors don’t want to adopt electronic medical records systems (EMRs).
As sappy as this may sound, most physicians were drawn to medicine because they wanted to help people, save lives, and improve the quality of life for those suffering from disease. Even after we’ve been beaten up by our training programs, and weighed down by debt and the mountains of paperwork required by a broken healthcare system, most of us still retain that do-gooder kernal inside us – we genuinely care about our patients.
And so because we care, we know instinctively that the human side of medicine – the attentive listening, the visual cues, the continued eye contact, and the careful history and physical exam – is critical to our profession. The problem we have with EMRs is that they often interrupt the sensitive and intuitive parts of what we do. EMRs and other digital “tools” designed to make our work more efficient, may do so at the expense of the human connectedness our patients deserve and need.
Most EMRs, as they exist today, are not designed to bring patients into the conversation. In order to maximize efficiency, the physician must type while the patient is talking – usually turning their gaze and even their whole bodies away from the individual or family. Those of us who feel that this behavior is socially inappropriate will take a verbal history from the patient and then type it up from memory later – this creates more work than if we’d simply taken notes during the conversation in a paper-record, and may introduce recollection bias if we do our typing at the end of a long day of seeing many patients.
There is certainly a generation gap in terms of EMR adoption (as my friend Dr. Geeta Nayyar has noted) – our new crop of doctors are very comfortable with EMRs and wireless tools of various kinds, while the “older” doctors are often highly resistant to adopting a digital system. But before we label senior physicians as “obstructing progress” – let’s look beyond the technology issues (yes, it takes time to learn how to do something a different way) and at some of the emotional reasons why physicians don’t like what EMRs do to their patient relationships.
Time and again I’ve heard my peers (who use EMRs in hospitals) say that they feel that they spend most of their time “talking to the computer” rather than the patient. They are wracked with guilt about this, and have actually lost a portion of their “job satisfaction” as a result. They know that the digitization of healthcare has robbed them of the luxury of full history and physical exams, conducted in an uninterrupted face-to-face encounter with their full attention on the patient. They feel like a robot – like a mere collection of algorithms used to process people in an “evidence based” framework. And the patients – they report that their doctors are hurried, uncaring, and potentially replaceable with a robot.
In my opinion, EMR manufacturers must understand the collateral damage that their products can do to the physician-patient relationship and create EMRs that engage patients in the physician encounter. I have seen at least one prototype product that is trying to do this (and there may be many more – it’s difficult to keep up with all the new innovations, so please leave a comment about other products that you know of), Microsoft’s Surface. Surface allows the physician and patient to sit together at a table with a screen embedded in its top. The physician can bring up lab results, radiology images, and medical records to discuss them with the patient so they can see it at the same time. I really like this concept, since it facilitates electronic record keeping while engaging the patient in the encounter.
When EMR vendors and civil servants bemoan the slow technology adoption rates of physicians, I urge them to recognize that there is more at play than just “resistance to change.” There is a resistance to dehumanizing doctor-patient interactions, to turning one’s back on a crying patient to type notes on a laptop, to spending more time “talking to a computer” than talking to a patient. That resistance is actually a good thing – it means we still care, we have hearts, we are human.
Now, to get physicians to adopt EMRs – don’t use a stick (“adopt our EMR or we’ll fine your practices”) use the younger generation of physicians (already comfortable with technology) to teach the older ones how to integrate digital record keeping into their workflow. During that interaction, I believe the senior physicians will be able to teach the junior ones a lot about the art of humanizing their patient interactions, while the younger ones train them about the technical process of incorporating EMRs into their own workflow.
In summary, EMR adoption is slow not just because of cost and technical skills barriers, but because of the potential dehumanizing effect they can have on medical practices. Senior physicians may understand this risk better than junior ones, and should be admired for their desire to maintain fewer barriers in their relationship with patients. EMRs created with the ability to include patients in the conversation can reduce the potential social damage they often introduce in patient encounters. Peer-to-peer training is valuable in improving adoption rates, teaching junior physicians the social etiquette important in a caring doctor-patient relationship (and to maintain the art of listening and observing), and helping senior physicians learn how to use technology to achieve the tasks they currently complete by other methods.
June 2nd, 2009 by Geeta Nayyar, M.D. in Expert Interviews, Medblogger Shout Outs
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I attended the 29th annual Management of Change (MOC) Conference with Dr. Val. The conference is sponsored by the American Council for Technology and the Industry Advisory Council. MOC brings together government and industry leaders to share knowledge, collaborate, and develop actionable technology management strategies. As a physician, attending this conference for the first time, I assumed a great deal of the conference topics would be over my head and in very “techie” terms. My hope was to get a glimpse of some of the technology solutions the government was considering as they relate to health care IT.
Vivek Kundra, first Chief Information Officer of the United States, addressed the audience early in the day in language that even a doc could understand. He spoke about the need to simplify government, and connect people to solutions, instead of “endless bureaucracies.” The same of course goes for medicine. How great would it be to connect our patients to systems that actually had interoperable medical data?
I was able to catch up with Mr. Kundra after his talk for a few minutes and ask him how technological simplification would apply to physicians such as myself, operating in a haphazard infrastructure with varying PAC systems, EMR’s and paper charts. He said the key would not only be investing in technology, but investing in training healthcare personnel to master new technologies. He acknowledged that different generations of physicians would embrace technology differently, but ultimately, if a physician says he “can do a better job on paper” then we have a problem.
I was very impressed by Mr. Kundra’s answer namely because it was so insightful for a man who’s expertise lies primarily in the technology field. He does not come from a healthcare background, and yet had hit the nail on the head. There has been so much talk about HIT being the “key” to cost savings and the next “breakthrough” in medicine. With very little discussion on how physicians feel about it. For some docs – particularly those that come from an older generation – the thought is quite terrifying. They are happy with their paper charts and manual dictations. Health technology is almost viewed as an impediment to those set in their ways, and accustomed to a system that has worked for them and their patients for years. This upheaval will not come without it’s challenges even after we find the best technologies for the tasks at hand. It will be imperative for government leaders to understand that the mission of HIT implementation may be just as difficult as finding the technology solutions they are currently seeking.
As Mr. Kundra and his team embark on this huge task, it will be important for physicians and health care personnel to engage with the government and serve as a guide for what docs need from technology, and what will and will not work for our patients. I hope next year’s conference is attended by more physicians such as myself and Dr. Val.
May 29th, 2009 by DrWes in Better Health Network
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There are some things that Electronic Medical Records do well and there are some things that Electronic Medical Records do poorly. To say that I need Electronic Medical Records to help me type is nothing short of ridiculous. Unfortunately, when engineers meet computer programmers and try to help health care professionals type in the health care record in the name of “safety,” the results can torment those they’re trying to help.
Take auto-spelling, for instance. I have the nasty habit of typing “Lungs: Claer to A&P” and marvel at the auto-correction feature automatically correcting my typing to “Lungs: Clear to A&P.” This is an example of the wonders of electronics.
But when I type “DC Cardioversion” and the computer won’t left me type “DC” because it wants to know if I mean “discharge” or “discontinue,” the computer becomes intrusive, obstructive, and performs a service that should be right up there with water-boarding. I mean, is someone really going to mistaken that I mean “Discontinue cardioversion” or “Discharge cardioversion” when I’m typing my operative report? I could see this being a problem in the order-entry portion of the software, but when I’m typing by progress note or operative note?
Please.
Even better are the wonderfully useful letters “MS.” These might mean “magnesium sulfate,” “mental status,” mitral stenosis, “MS Contin,” “multiple sclerosis,” “musculoskeletal,” “Ms.,” or maybe even “Mississipi.” So, instead of being able to type a logical sentence without interruption, the doctor finds that that a drop-down pick list prevents those magic letters from being typed. It seems the chance that a nurse will wonder if you’re prescribing a drug in a southern state trumps the ability to enter a simple sentence on the computer. This is, after all, how we’re preventing medical errors.
But I wonder if these computer engineering road blocks are doing something much more insidious and detrimental to our health care delivery of tomorrow: like devaluing independent thought, reason, permitting the subtleties of context, and common sense.
No, better to torment instead.
