May 26th, 2009 by KevinMD in Better Health Network
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The following is a reader take by Paul Ravetz.
Does the “Art of Medicine” really exist, or perhaps more importantly, can it do so in the computer age?
Computers are both the boon and the bane of medicine. Electronic medical records (EMRs) are excellent for retrieval of information about labs, medications, and past medical history of our patients. These records are much easier to access than our old paper charts. However, I feel that the Achilles Heel of these advances lies in the fact that physicians are so busy inputting information into their computers that they do not spend enough time communicating with the patient.
Communication with your patient is the epitome of the Art of Medicine. It is vital that physician and patient understand each other. This includes not only what the patient says but what they mean. This takes time, a commodity which is in short supply in the age of EMR. One should always remember a basic caveat about computers, which is, “garbage in, garbage out.” If wrong information is fed into the computer, it doesn’t matter what algorithm that you use because you will be following a false trail.
Computerization of medicine will lead to great advances if it is implemented properly. However, the way things are presently being done cheats the patient out of the most important part of the doctor patient relationship – time to communicate. I always remember the precept advanced by Sir William Osler, the father of modern medicine, “Listen carefully doctor, the patient is giving you the diagnosis.”
The combination of the computer age along with the time to listen to the patient and to accurately define their problem will indeed lead to a new age in medical care, but to ignore one or the other is not to fulfill our obligation to our patients.
Paul Ravetz is a family physician.
*This blog post was originally published at KevinMD.com*
May 3rd, 2009 by KevinMD in Better Health Network
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Bolstered by the stimulus, there’s no doubt that there’s a significant push for doctors and hospitals to adopt digital medical records.
I’ve written before how we’re essentially throwing money at Windows 95 technology, but now, as an article from BusinessWeek points out, there’s a real danger in moving too fast.
Somewhat under-publicized were the incompatibilities with older systems in the Geisinger Health System, which after spending $35 million on software, noticed a spike medication errors that required another $2 million to fix.
Or what happened at the University of Pennsylvania, which found medication errors stemming from software designed to prevent mistakes.
Worse, there is no national database tracking the errors that are caused from electronic medical records. Because most of the programs are not open-source, confidentiality agreements meant to protect proprietary technology also serve to hide mistakes.
Ideally, these issues need to be resolved before throwing more money into bad technology. But, because of the intuitive notion that technology automatically improves health care, no one seems to be advocating a more cautious route which may, in actuality, better serve patients.
***
Better Health Editor’s Note: Please read this post for more in-depth coverage of how difficult it is to transfer health records electronically.
March 31st, 2009 by DrRob in Better Health Network
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Our office has been on Electronic Medical Records (EMR) for nearly thirteen years. We see a high volume of patients, keep our overhead down, and are able to be quite successful financially. All of the “EMR is impossible” and “EMR makes things worse” stuff you read around the web are disproved quickly with a step into our office. We implemented EMR successfully in a private practice setting without help from an economic stimulus, a hospital system, or a magic wand.
Not that it was easy; we went through many years of struggle to get to where we are today. We struggled mainly because we were exploring unknown territory. We had very few other successful EMR implementations to learn from. We used slow computers and programming developed in the pre-Internet era. We made huge mistakes and struggled at times to make our monthly budget.
But we did it, and practices implementing now can learn from my and others’ success. Probably the main lesson we learned is to put office function ahead of implementation. Since we are a business, we must stay profitable while implementing. Since we are practicing medicine, we must never compromise quality in the process. This meant that we implemented over time, focusing on parts that would either improve our process or at least not bring us down.
Now we are at the position I thought might never come: survival is no longer in question, so we can dream. We don’t have to act defensively, we can push the envelope. We can afford to ask the question: “How can we build the best medical experience for our patients?” We can imagine a destination and actually attempt to get there.
The ideal destination is one in which our patients’ care is improved by maximizing efficiency on our end. Obviously I don’t want to make things harder for our practice, I want to make things easier. But the goal of care is ultimately centered on the patient, not us. So is there a way to accomplish both goals? I think there is, and I think that our EMR is the tool that makes it possible.
Here are our goals in the process:
- Simplify how things are done
- Always have the right information available
- Make communication clear and easy
- Achieve the highest quality possible
I’m sure some think this is just idealism and can’t happen in reality. I agree and disagree. No system can be perfect, but the current healthcare system is so inefficient and ineffective that huge gains can be made. The best way to show that is to get down to specifics. Here is where our practice is heading:
Simplify
The thing that takes the most time away from actual patient care is documentation. Doctors are paid by the volume of documentation, not its quality. Still, the main purpose of a record is to accurately know what is going on with the person facing you in the exam room. Unfortunately, the patient is continually changing, so some information is only accurate for a short time. Has the patient seen a specialist or been in the hospital? Have the medications been changed, or just not taken? Have they changed jobs, quit smoking, or gotten married? Did their sister just get diagnosed with cancer? The task of keeping this information up to date is extremely difficult.
Patients are the ones who know these things best, but they are only passive participants in the process. To keep the record accurate, I must ask them all the right questions on a regular basis. This cuts into time that should be devoted to care. So why can’t the patients be allowed to maintain this part of the record? Why shouldn’t they have access to parts of their record and the ability to correct errors? Here is how we see this happening:
- Certain parts of the record should be available for patients to review online. Basic demographics, medications and allergies, family history, and lifestyle information is a good start. If something new has happened, the patient can either update this information directly (like marital or smoking status) or notify the office of changes (like medication lists).
- If the patient doesn’t update it online, then they can do so when they come into the office (while sitting in the waiting room). Some people will undoubtedly not want to do this, but a significant percent will, decreasing the workload on the office while maximizing the quality of information.
- Patients should be able to communicate important information to the office online. If they go to the ER or see a specialist, if their blood pressure or sugars are high, they should be able to send that information directly to the physician.
Another area of potential gain is the gathering of information for a visit. When a person comes to the office, they have to answer a series of questions related to the visit:
- what are the symptoms the are having?
- Are there any other symptoms?
- How have they been since the last visit?
Gathering this information is essential, but it is one of the main causes of delays. Here is how we want to employ technology to improve this process:
- Put kiosks in our waiting room where patients can provide information, such as:
- History of their present illness. If they are sick, then what are the symptoms and how long have they gone on?
- Review of systems. What other things are going on in their health?
- Medication and demographic review (if not done already online).
- If patients fill out information online before coming to the office, the staff will bring them to see the doctor immediately (or at least as soon as possible).
Even 50% participation by patients in this process will have a huge impact on our office workflow. The end result is a win-win: the patient is seen sooner, the information is more accurate, and the workload of the staff is reduced. Will there be problems? There always are; but the advent of ATM machines, airport kiosks, and online shopping are a few examples of process automation that have greatly improved the customer experience. Why should medicine be different?
I am going to stop here, as I don’t want to lose you (if you haven’t already whacked the keyboard with your forehead). Hopefully you can see that the use of technology applied smartly can help patients and medical offices at the same time.
And this is just the start.
**This post was published originally at Musings of a Distractible Mind blog.**
March 25th, 2009 by SteveSimmonsMD in Primary Care Wednesdays
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Anyone working in healthcare has a moral responsibility to do the right thing, for the right reasons, and at a reasonable price; however, this is not happening. Today’s healthcare system is too expensive and it is broken. If it wasn’t broken, the current administration would not be focusing so much money and effort on fixing it. Likewise, 42 million Americans would not be uninsured creating two different standards of care within our country. Many decisions have already been made: providing government backed insurance coverage for the uninsured, encouraging the use of electronic health records systems (EHRs), and creating comparative effectiveness research boards (CERs). Much of what has been suggested sounds good but was passed by our legislature before seeking the input of those responsible for implementing these new policies and plans. Fortunately, President Obama’s administration is seeking input now and it is the responsibility of anyone working within the healthcare system to speak up and be heard.
Many hard-to-answer questions should have been asked before solutions were posed. Why is healthcare so expensive? How can the intervention of government lead us to better and more affordable healthcare? Although integrated EHR systems may prevent the duplication of tests and procedures, how can medical practitioners best use these systems to prevent mistakes? How will future decisions be made – between doctor and patient, or will the new CER Boards grow to do more than merely advise? How would the American people react to more controversial ideas, such as health care rationing to control exorbitant costs incurred at the end of life?
In my last post, I closed with a promise to share some ideas regarding healthcare reform. First, we should try to reach a consensus as to what is broken before implementing solutions. In Maggie Mahar’s book, Money-Driven Medicine (2006), her concluding chapter is titled, “Where We Are Now: Everybody Out of the Pool.” This title screams for change as she makes a convincing argument that all parties involved in healthcare need to rethink how we can work together to fix a broken healthcare system which seems focused, not on healthcare, but on money. Today, Uncle Sam has jumped into the pool feet first, creating quite the splash, and he is spending large sums of money to lead healthcare reform without first reaching a consensus as to what is broken in this system.
The American Recovery and Reinvestment Act of 2009 will direct $150 billion dollars to healthcare in new funds, with most of it being spent within two years. Health information technology will receive $19.2 billion of these dollars, with the lion’s share ($17.2 billion) going towards incentives to physicians and hospitals to use EHR systems and other health information technologies. According to the New England Journal of Medicine, the average physician will be eligible for financial incentives totaling between $40,000 and $65,000; this money will be paid out to physicians for using EHRs to submit reimbursement claims to Medicare and Medicaid, or for demonstrating an ability to ‘eprescribe’. This money will help offset the cost of implementing a new EHR, which can cost between $20,000 and $50,000 per year per physician. However, after midnight, December 31, 2014, this “carrot” will turn into something akin to Cinderella’s pumpkin, becoming a “stick” that will financially penalize those physicians and hospitals not using EHRs in a “meaningful” way.
At our office, doctokr Family Medicine, we use an EHR, but consider it a tool, much like a stethoscope or thermometer, used to facilitate the doctor-patient relationship, not a tool to track our reimbursement activities. I would not argue against EHRs, but there is no evidence they will make healthcare more affordable and improve the quality of care delivered – unless you believe the $80 billion dollar a year savings “found” in the 2005 RAND study (paid for by companies including Hewlett-Packard and Xerox- incidentally, companies developing EHRs). I believe it will take far more than EHRs, financial incentives, and good data to fix our broken healthcare system.
Difficult decisions await those willing to ask the hard questions but don’t expect any easy answers to present themselves on the journey towards effective healthcare reform. My partner and I believe we have found answers to some questions and are moving forward, in our own practice, now. Asking why healthcare is so expensive and feeling frustrated with the high cost of medical software, we have written our own EHR, containing costs for our patients by keeping down our overhead expenses. Our financial model is based on time spent with the patient, not codes and procedures, which helps us to avoid ‘gaming’ the system and wasting time.
A familiar adage states that there are no problems, only solutions. I suggest, though, that there can be no solutions without problems. Find the right questions and opportunities abound. Earlier in this post, I asked how government intervention can lead us to better and more affordable healthcare. It can’t, at least not without the help and guidance of doctors, patients, industry, insurance companies, hospitals, and anyone who understands what is at stake with health care reform. We all share in the responsibility to try.
Until next week, I remain yours in primary care,
Steve Simmons, MD
March 21st, 2009 by DrRob in Better Health Network
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Electronic Medical Records are coming. The economic stimulus bill (furious spinning kittens notwithstanding) assured this.
Under the terms of the bill, CMS will offer incentives to medical practices that adopt and use electronic medical records technology. Beginning in 2011, physicians will get $44,000 to $64,000 over five years for implementing and using a certified EMR. The Congressional Budget Office projects that such incentives will push up to 90 percent of U.S. physicians to use EMRs over the next 10 years.
Practices that don’t adopt CCHIT-certified EMR systems by 2014 will have their Medicare reimbursement rates cut by up to 3 percent beginning in 2015.
(From Fierce Health IT)
There will be even more money for implementation. We look forward to our checks (and are not counting on them yet).
Now it is time for the flies to start gathering. Wherever there is lots of money, “experts” pop up and new products become available that hope to cash in. Doctors, who are never lauded for their business acumen, will be especially susceptible to hucksters pushing their wares. It seems from the outside to be an simple thing: put medical records on computers and watch the cash fly in.
Anyone who has implemented EMR, however, can attest that the use of the word “simple” is a dead giveaway that the person uttering the word in relation to EMR is either totally clueless or running a scam. It’s like saying “easy solution to the Mideast unrest,” “obvious way to bring world peace,” or “makes exercise easy and fun.”
Run away quickly when you hear this type of thing.
Just like becoming a doctor is a long-term arduous process, EMR implementation happens with time, planning, and effort. It’s not impossible to become a doctor, but it isn’t easy. With EMR adoption, the most important factor in success is the implementation process. A poorly implemented EMR isn’t simply non-functional, it makes medical practice harder. A well implemented EMR doesn’t just function, it improves quality and profitability.
How do I know? Our practice ranks very high for quality (NCQA certified for diabetes, physicians are consistently ranked high for quality by insurers), and we out-earn 95% of other primary care physicians. EMR allows us to practice good medicine in a manner that is much more efficient.
So how’s a doc to know who to trust? What product should he/she buy and whose advice about implementation should they follow? There are many resources out there. Here are a few I think are especially worthwhile:
- Buy a product that is certified by Certification Commission for Health Information Technology. CCHIT is a government task force established to set standards for EMR products. Its goal is to allow systems to communicate with each other and enable more interfaces in the future. The bonuses for docs on EMR are contingent on the system being CCHIT certified (think of it as something like the WiFi standard).
- The American Academy of Family Physicians’ Center for Health Information Technology and the American College of Physicians both have tools to help member physicians decide on an EMR. Your own specialty society may, too.
- Several professional IT organizations have programs to improve EMR adoption, including HIMSS and TEPR.
- Austin Merritt has written a good article of advice on his website Software Advice that underlines the importance of implementation.
The best advice I can give, however, is to visit a doctor’s office who is using an EMR successfully. This office should be as close in make-up to your office as is possible. You should be able to look at how they do it and see yourself in that situation. Never buy a product before visiting at least one office like this (no matter how good the sales pitch). When you visit, make sure you ask them about the implementation process. How did they do it and how hard was it?
Which EMR do I recommend? Remember, I have been on EMR for over 12 years, so haven’t had much of a chance to shop around. You hear raves and horror stories with every product. Here is some basic advice:
- Get a solid CCHIT-approved brand that has been around for a while
- Don’t pay as much attention to price as you do function. Since the EMR will be absolutely central to the function of your office, it is a dumb mistake to overly-emphasize cost.
- Realize you are paying for a company, not just a product. It is not like buying a car, it is more like having a child or getting married. REALLY research that side of things. A good EMR with a bad company behind it should be avoided like the plague.
- See how connected the user-base is as well. A solid user group will do much to make up any deficiencies in the product and/or company.
So much time is spent shopping over EMR products, but buying an EMR is like being accepted into Medical School; your work is just beginning. That’s OK, because like medical school, the effort put in gives a very worthwhile product.
**This post was originally published at Dr. Rob’s blog, Musings of a Distractible Mind.”
