An EHR Fantasy

Now that I've been using my EHR for more than three months, the muscle memory has taken over but there are still only so many clicks I am capable of doing in any given moment. Locating the right forms to insert, deciding how many templates to download, determining if I should plug the microphone back in between patients or carry it from room to room, figuring out the most expeditious way to document in the problem list from a scanned referral note or lab results and finding new ways to record a note, these things are all going to take a lot of time. Yesterday I came across an interesting article by Marla Durben Hirsch from the FierceIT blog: EHR vendors propagating a myth about their products. Amusingly enough, the article made me daydream:

I am in a room with a patient, iPad in hand. With touchscreen input, I easily target any templated buttons with my finger (instead of missing it with the stylus because it's not quite in the 'sweet' spot). There is a graphical interface that's pleasant to the eye, usable and intuitive. Dictation feeds directly into the chart from an adequately programmed microphone IN the iPad, so I don't have to cart a separate piece of equipment with a ten-foot wire. There are separate modules for each specialist and a broader one for me, the family doc. If I misspell a word, there is a spell-checker (incredibly, something my present EHR is without). To show an illustration to a patient I simply double-click the home button and choose the browser for the internet or another app to illustrate a point. If there's a video I'd like a patient to see it's up in an instant. From the iPad I can quickly email links, videos or relevant information to the patient. It rarely crashes, the screen can be enlarged or reduced depending on my needs. It is smaller than a laptop and less obtrusive than paper charts. I add apps specific to my interests or my patients. And they don't cost an arm and a leg. 

Alas I come back to the real world where my stylus still has to be placed just slightly to the left of the circle I'm aiming at. When I suggest to my IT support that hiring gaming developers might be a great way to improve the interface of our present EHR I'm really not kidding. Seriously, making patient documentation something inherently usable would go far to improve the acceptance of them with physicians. Despite claims to the contrary, physicians LIKE tech. We just expect the tech to be user-friendly. More specifically, we expect EHRs to work like the apps on our phones and our tablets. What a joy to look at a screen like this:

From the app iBP by Leading Edge Apps LLC

But no, my screen is riddled with tiny mono-color dots and clickorrhea is the name of the game. 

While patient care is serious there is no reason why electronic documenting could not be a joy to use. As more digital natives enter medicine they will be more insistent that the software they use to take care of patients be as easy to use as the apps they use to monitor their heart rates with exercise, check in with Foursquare, or text their friends. From my perspective, they can't get here fast enough!

The Thanksgiving Z-pack

Emma & Great Uncle Tim

Thanksgiving this year is likely to become one of my favorite holiday memories. My husband's niece, her husband, sister and fifteen-month-old daughter visited from Mississippi. We had a nice time showing them our pretty Louisville Zoo where Emma got a new hat to protect her ears. We ate a delicious turkey dinner, checked out some restaurants and explored Christmas lights in the "MegaCavern" which was an old crushed-stone mine now used for rentable storage and zip-lining.

Belle of Louisville in lights.

My daughters stayed up late with their cousins while Tim took to his job as great uncle with enthusiasm.

This year I was on call for our office which is usually quiet but a long weekend can be busier especially since we elected to keep the office closed on Friday. Typically the calls concern respiratory infections and urinary tract issues.

As I explained the normal symptomatology of an upper viral infection (or cold) to the patient on the phone Thanksgiving day, I noticed my husband's niece listening. When I got off the phone I said, "Everyone thinks a Z-pack is going to make them better. Typically the request for an antibiotic is about halfway through the process and in a few days, they feel better. They assume it's from the antibiotic but in reality, they were going to get better anyway." I could see the wheels turning in her head. "My doctor always gives me an antibiotic." So we talked about the negative aspects of getting an antibiotic every time she has a respiratory infection. The virus won't respond to it but the bacteria that live in and on her can become resistant to antibiotics. She will be at increased risk of developing MRSA--methicillin resistant staph infection, a skin infection that is difficult to treat. If she does develop a bacterial-caused illness such as a true bacterial sinus infection (usually one-sided sinus pain, purulent nasal drainage AND a fever), a skin infection, urinary tract infection or pneumonia, it may take stronger and more toxic antibiotics to kill the organisms. It is even possible that the infection could be fatal. A good over-view of this topic is here.

She was pleased that the pediatrician had not given her daughter antibiotics, even though Emma has been seen several times for various upper respiratory infections and stomach bugs. She commented that most of her friends' children were frequently treated with them. Obviously she can't control what the doctor prescribes for her but maybe next time she will ask, "Is the antibiotic really necessary?" Sometimes that is just the opportunity a provider needs to say "No, it probably isn't. Let's just try a little symptomatic relief and lots of fluid and rest!" Maybe another participatory patient was born this holiday.

A Humbling Experience

As Physicians are becoming aware, consumers of health care products (better known as patients in my world) are increasingly likely to leave reviews of their physicians on sites such as Healthgrades, RateMDs and Vitals. Of course the angry patient is more likely to vent criticism than the satisfied one unless the physician's practice is actively encouraging patients to go to the sites.

I use a service that emails me once a week with my data listings on several rating sites, including the ones included above. Rarely is there anything new but yesterday my email indicated a new evaluation. I clicked on the link and found the following comment, "Rolled her eyes at me with her head bent down when I told her I thought I had something going on--I presume she thought I couldn't see that gesture." Ouch! It is certainly not inconceivable that I did that. It is, however, very unprofessional. Was I burnt out that day? Was I actually rolling my eyes at the computer that tries my patience on an on-going basis? Had it been a horribly unproductive day and I wasn't listening the way I should have been? Whatever the reason the behavior was completely inappropriate. I believe in patient-centered care. No matter what was going on with me that day, my patient should not have felt undervalued and patronized. In checking the patient schedule from the day the review was written and the day before I could find nothing outstanding. Fortunately the review site allows physicians to comment (many don't) so I took the opportunity to apologize. More importantly, this gave me an opportunity to think about my reactions to patients and remember to pay more attention to my interactions, especially on days when I am frustrated or tired.

Physicians have long been protected from such reviews but as more and more "quality" data is released to the general public by the Centers for Medicare and Medicaid (CMS), not only will specific comments from patients be available but sites like Angie's List and Consumer Reports will use that data to rate physician practices.

It's a scary world to physicians, but frankly some days I need a little constructive criticism. The good news is when I get this critique: "Excellent physician. Will not tell you what you what to hear but tells you what you need to know. Does not claim to know it all and will refer to specialists (the best available) without a second thought. I trust her with my life and have for 19 years." 

Price Transparency in Medical Care

As healthcare costs become a bigger and bigger chuck of our Gross Domestic Product (GDP), price transparency is a subject that insurance companies and patients are talking about. The idea of knowing how much something costs, be it canned black beans in the grocery store or replacing the leaking faucet in your kitchen, seems obvious but it will be an uphill battle to enact change within the healthcare system. The concept seems simple--make prices accessible to the people who are paying them just like in any other service industry. While healthcare is more complex than a plumbing job, there are still some things that should be easy to price--cataract extraction, blood pressure check, yearly physical, uncomplicated appendectomy. The hidden prices and unknowns in medicine can quickly add up. It is no wonder that  patients are angry, frustrated and incredulous.

Case in point, my mother called yesterday to ask why she was not told that going to a cardiologist in our system for a test was "outpatient treatment" in a hospital. She had no idea that was the case until the  EOB (Explanation of Benefits) came from her insurance company with a charge specifically associated with that. The answer is that the cardiologists are employees of the hospital so there is an additional fee tacked on to her bill. Even though her visit appeared to be in a doctor's office, it is now an extension of the hospital. As such they tack on a "facility fee" that, while technically allowable, I find distasteful and misleading, even as it is done by my own healthcare system. Talk about a lack of transparency! My mother had no clue and at 84, even if someone did explain it to her, I doubt she understood what they were talking about. Not until she got the EOB from her insurance company did she start to question.

A patient with congenital heart disease told me this week she was putting off getting an imaging study on her heart because she can't afford the $1000 hospital fee that her now-hospital-employed physician would be adding to her bill. One thousand EXTRA billed dollars solely for that reason??? How do hospitals justify this? They state that patients are paying for the "added services" that being a hospital-associated facility affords them, like infection control and patient safety. I doubt anyone thinks paying four times what the doctor charges for a facility fee is justified by patient safety. For another take on this please read: Medical Billing: a world of hurt.

It's encouraging to see patients becoming more involved in this process--pushing for price transparency[1]. Doctors are also beginning to understand that we can no longer hold ourselves above the fray, believing that caring for the patient in the best manner possible without knowing the economic burden that care incurs to the patient or family is not our concern. Best care does include knowing costs. In the meantime, my patient who needs the echocardiogram waits, and hopes for the best.

1. Outofpocket.com. Lori, Mona. Frisbie, Patrick. 11/07/12. Flying Aces Incorporated Inc. 11/10/12 http://outofpocket.com/Blog/2012/11/07/TheBiggestQuestionNoOneIsAskingInHealthCare.aspx

Patient Access to Their Data

The Open Notes initiative has created a flurry of interest in the on-line medical community but not even a blip that I can tell in my personal world. Patients appear oblivious. The story was not covered by our local newspaper. No physicians are nervously or otherwise discussing it in our doctor's lounge.

Despite Meaningful Use criteria breathing down our organizations's neck, which includes patient portals with the capability to obtain their records electronically, no one is talking about this important study: three healthcare systems, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in  Pennsylvania, and Harborview Medical Center in Seattle participated. This included 105 doctors and more than 13,000 patients. When the study was finished 99% of patients surveyed wanted continued access to their notes and NO DOCTORS opted out. 

The last phrase is the most important one to me as a physician. In my world doctors are often very nervous at the thought of patients obtaining access to their own records even though technically the patient owns the record. Yet the more I see of charting, especially electronic charting, the more important it is that patients have the ability to access and help us improve their records. 

As an example, I recently had a new patient who related being involved in a motor vehicle accident many years ago. He'd had surgery shortly after but he wasn't sure whether or not he'd had his spleen removed, though he knew it had ruptured. This is important because individuals who have no spleen are at increased risk of certain kinds of infections and need routine and regular followup vaccinations to protect them. The first thing I did was access records from an abdominal hernia surgery he'd had just a few years ago, to repair a hernia he had as a result of the first surgery. The operating doctor dictated in his note that the patient had had a splenectomy. I wasn't convinced so I dug a little further and fortunately the hospital still had records of the first surgery (by law the hospital does not have to keep records from over twenty years ago). The patient did not have his spleen removed and thus needs neither recurrent vaccinations or  expensive imaging to figure out the answer. But what if I'd just taken the mistaken word of the second surgeon? How much better if the patient had been given easy access to his records years ago when he'd first wondered? 

Soon, patients will have access to their own charts and will be capable of giving much better histories or better yet, will have their medical stories in their own Personal Health Records. This can save a lot in time and unnecessary tests, not to mention improved accuracy in patient records. Because after all, who has more at stake in the accuracy of the record than the patient? Or as e-Patient Dave deBronkart says: