Be Careful What You Wish For

Physician-to-physician communication has become an increasingly difficult problem and its lack has worsened the fragmentation of healthcare today[1]. The challenge is complicated by many things:

• Physicians lack the time to call colleagues about patients when their income is patient volume-based 
• Fewer opportunities for direct physician contact, i.e. the doctor's lounge
• EHR systems cannot talk to each other
• Patients don't always tell their physicians about other doctors taking care of them
• Printed EHR records are so full of verbiage that important findings are missed by the doctors trying to scan pages of unimportant documentation
• Patients rarely carry their health histories with them in any format outside of memory

Another problem, at least in the healthcare system where I work, is the lack of a centralized area where physicians can come together to find community specific information. Blast emails are sent to doctors whose boxes are already full of "junk", making it difficult to separate the wheat from the chaff. Recognizing this problem I recently approached the IT department at my institution. 

It was gratifying to me that they not only understood the issue, but were excited about assisting in a solution. My vision is to create a Physician Community where providers can go to find answers and communicate in a secure environment about any number of issues--problems with EHR, announcements, medical directors' updates, calendars with CME and other dates of interest, blogs, CME, vlogs, links to outside trustworthy medical sites, and a place to crowdsource patient or system problems. IT gave me access to build such a community in a Sharepoint environment. 

Of course in addition to the problem of building the environment and populating it with what the doctors need, is getting them to use it. I feel certain that "If you build it they will come" does not apply in this situation. I envision needing to enlist lots of assistance from the President and CMO of the system down to the office managers and EHR superusers. 

I'm a firm believer that Social Media is the most important revolution in patient care today. Effective electronic communication between physician is part of that movement. But today, as I'm reading Sharepoint for Dummies, I can't help but wonder--what was I thinking and can this make a difference? 

References:

1. Shannon MD MPH, Shannon. peg.org. January/February 2012. http://www.perfectserve.com/resources/docs/ACPE-PhysicianCommunication.pdf

The Catch-22 of the Physician Champion Role

Yes, I'm a geek. When my girls were in high school, their friends were amazed that they received texts from their mother. One daughter has commented on Facebook that her mother is more tech-savvy than she is. At the beginning of 2012 my interest in the healthcare benefits of social media was born and I began blogging. I investigated and use LinkedIn, Twitter and Google+ while remaining attentive to Pinterest, AboutMe, Doximity, Instagram and others. So when my employer offered me the position of EHR Physician Champion for our physician group a couple of months ago, I took on the challenge. And challenge is the operative word.

Presently there are about 25 physicians in our 180+ multi-specialty group "live" (using electronic records). In a meeting specifically called to discuss "Provider Go-Lives", three individuals tasked with implementing EHR turned to me and said, "So Dr. Nieder, how can we encourage doctors who are not embracing EHR to do so." Hmmm....good question.

Let me preface these remarks by stating that our administrators have tried everything in their well-researched knowledge base to make this transition work. As we move forward improvements are made with every new Go Live. My immediate response was two-fold:

1. In training, don't give physicians the impression that using an EHR is using a paper chart in electronic form. It is an entirely new way to document and, unfortunately, the learning curve resembles third year medical school with IT support instead of attendings. It is every bit as daunting. 
2. Encourage the doctors to shadow with someone already successfully using the system. 

The next question was harder. "What can we do to push the physicians who are balking?" Ah, therein lies the rub. Of course I recognize that the question was also my responsibility in the role of Physician Champion. To answer it, I was going to have to do some thinking. There are many reasons doctors give for not wanting to use EHR as posts by Palmd, HealthcareTechReview, MITTechnologyReview, and others attest but the biggest one in my system is that it slows down physicians whose salaries are based on productivity. 

My understanding of the value of EHR is simple enough--more legible notes, better population care using "big data", enhanced patient care using clinical decision support tools, improved documentation to increase reimbursement, establishment of direct patient communication through portals, healthcare savings by reducing duplicate test ordering, and improved communication between providers in continuity of care. Even though our present system is poised to realize all these goals, the only one it is capable of performing at this very moment is legibility. So how can I convince physicians to use a tool that is going to slow them down (i.e. reduce their pay) and doesn't yet have the necessary functionality to improve patient care?

As a geek, the EHR experience has me torn between two emotions: incredulity at its lack of usability  and that sinking sensation I remember from the late 80's when the software rarely did what it was advertised to and crashed all too frequently, freezing the computer and forcing the user to restart both the software and often the entire system. The promise was there but the reality was long in coming. So too is today's EHR. 

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!

An EHR Obsession

My Saturday morning walking partner asked me yesterday, "So when do you get to quit being an IT professional and go back to being a doctor?" Wow, good question.

In the not quite three weeks of this new form of documentation I have been consumed with trying to understand and make the EHR work for me. No longer do I have to consult a "superuser" every ten minutes with questions but every day I'm trying to figure out the most efficient way to care for people using this frustrating new tool. The "muscle memory" is beginning to kick in thank goodness, so time per patient is less. Now my frustrations are more with what seems to be a very inefficient system. I struggle to determine whether I am the problem or the EHR is. Most likely it's a little of both. The term Mission Hostile User Experience coined by Scot Silverstein comes to mind. What is scary here is the potential for patient harm - between my distractibility due to the steep learning curve of the Allscripts system, the fact that no one has told us how to clean these "Toughbook" fomites that we carry from one patient exam room to the next, and the patient care error potential inherent in the software itself, these are the ever present worries that keeps me up at night.

On Thursday of this week, the EHR Steering Committee for my organization will meet and I will have the opportunity to present the go-live experience and make suggestions for improvement as other offices in the system go live. Throughout this process there has remained a sense of re-inventing the wheel, which seems odd considering that Allscripts EHR has been in existence for years, having gone public in 1999.

At any rate this blog is obsessed with EHR right now--but the essential question remains. When do I get to go back to taking care of patients?

Patient response to Electronic Records

Amazingly my patients have had a very patient response to the introduction of EHR (Electronic Health Records) to our office. They sit and watch me type and curse with an air of amusement and calm. More calm than I am feeling.

Yesterday began our third week of EHR. Muscle memory has kicked in and I saw 15 patients without running too far behind. Seeing 20ish patients daily again is starting to look feasible. Someone walking into my office no longer has to look over mounds of paperwork to see me. My only concern is whether my employers will cease to understand how much work I do if they can no longer see the physical evidence of it.

On an up note, there will soon be a couch in the area where the credenza is now. Since my colleagues warn me that it will continue to take longer to finish my charts it seems reasonable to have a comfortable place to do so. The main purpose of the credenza was to support the hundreds of charts I needed access to on a daily basis. The staff is very supportive of the change as well (wonder why...).

Many patients have followed me over the 25 years I've been in practice. While little has been different in the exam room until now, there have been lots of other changes--two previous locations, private practice to employed doctor, hospitalists, urgent care centers, and oppressive insurance controls to name a few. For the first time in two weeks, I was able to gauge patient reactions to this new-fangled way of documenting. Prior to yesterday I was too bogged down with clicking boxes, losing screens, figuring out where to put a new symptom the patient just threw at me, finding templates and vital signs and generally being absorbed by the Allscripts system to observe my patients (and please don't make me worry about what I may have missed in patient care over the last two weeks while I followed this steep learning curve).

Now I carry this new contraption in the room:

My younger patients hardly notice it. They would not have commented had I not explained its newness and why it was taking a little longer to enter information than usual. Older folks regarded it with expressions ranging from dismay to perplexity. Most of them commented before I did.

• "Do you like it?" 
• "Do you think it will ultimately speed you up or slow you down?" 
• "How hard is it?"
• "Did Baptist (my employer) force you to do that?"
• "What happens when the system goes down?" (I wonder about this one myself)

No one seemed particularly surprised or overly worried about my use of a computer to document their visit. They all seemed impressed when I stood up and said that their prescriptions were already at the pharmacy. 

At the end of the day what most impressed and humbled me was the sense that within their acceptance of this new device was a trust that regardless of the way I document their care, it would still be delivered in a way helpful to them.

At the end of the day, that's what it's all about, isn't it?

An Electronic Health Record misAdventure

We thought we were ready. We had all our training. The staff was pumped. The doctors were apprehensive but willing. Tuesday morning "GO LIVE" began. Fortunately the hardware folks just happened to be in the office installing our dual monitors, so there were two techs present when none of our medical assistants (MAs) could access their tablets. Uh oh...

Shortly into the day our office manager discovered that the stand-alone electronic prescribing software we'd been using for years had been turned off since Friday and prescriptions sent electronically since then had never made it to their destinations. Patients were calling. They weren't happy. And we had no way of knowing who they were because our workflow is to fill the prescriptions, document in the chart and file. Uh oh...

Meanwhile, my MA was still unable to use her laptop to triage my first patient. I was waiting...Dr. K had seen a patient, documented most of her note but she could not put in the plan for some reason. This was a problem that went on all day until it was determined that her 'profile' was corrupted. IT promised a fix by the next day. Uh oh...

Remember being told to "save, save, save"? Dr. I, not big on computers to start with, was humming along only to find out that one of her electronic notes, on a complicated patient, had vanished into the ether due to a Citrix glitch, never to be found again. She was nearly in tears. Uh oh...

Finally, my MA had a patient ready for me to see. Only an hour behind. It was a young man, a new patient in for what the scheduling staff was told was an uncomplicated physical. I remember being told that this patient was perfect for the first day on EHR "He's young and healthy, a great start to using the Health Maintenance Template". Except that he was drinking a pint of bourbon daily with a blood pressure through the roof, a urination issue, chest pain and was anxiously depressed. Uh oh...

It is very difficult to have one's attention divided by electronics when it needs to be concentrating on a real person's medical issues. If I had to grade myself with how well that first patient was treated by me, it would be close to failing. It felt like a return to medical school--working blind, feeling incompetent, trying to speak two different languages at once (electronic and paper) and never quite sure anything was being done well.

Rumor has it our skills will improve over the next year. My hope, as one of the first primary care offices to go live in our organization, the technical support staff and the doctors can help other offices begin this journey with a refined send off.

This is a hospital "go live" but still hilariously hit close to home:

Let's Ring in the New to Get Back to the Old

While reading a blog post by Dr. Kent Bottles I was struck by a quote from Lewis Mumford: 

“For most Americans, progress means accepting what is new because it is new, and discarding what is old because it is old. This may be good for a rapid turnover in business, but it is bad for continuity and stability in life. Progress, in an organic sense, should be cumulative, and though a certain amount of rubbish-clearing is always necessary, we lose part of the gain offered by a new invention if we automatically discard all the still valuable inventions that preceded it.”

Although Mr. Mumford has been gone awhile (22 years), part of his foresight, as I understand it, is that technology should serve humankind and not vice versa. The more things change the more things stay the same. Technology is infinitely more complex which makes it incumbent on IT and medical professionals that it serve to improve patient care and not worsen it. While I am jumping on the EMR (Electronic Medical Records) and Medical Social Media bandwagon, I am anxious to see that it is done in a manner that serves the patient more than me, the IT guy or the hospital where care is given. So many of the EMRs that I have sorted through as a provider makes patient care HARDER, not easier. Perhaps this will improve when, and IF, our different systems can talk to each other but now it is difficult to find labwork, tests, and pertinent history when wading through thirty pages of printed material that has nothing to do with the patient's problem. The important stuff gets lost in the minutia.

http://thecourse.webicina.com/

The EMR train has left the station and we will ultimately all be on board (how many transportation idioms am I going to use in this blog...). I see Social Media as a means to better care for patients, specifically as a way to return to patient-centered care and much more importantly, to get on the bus of participatory care. In The Social Media Course a well-known advocate for patient participation in their own medical care, e-patient Dave, addressed the fact that patients are the most under-utilized resource in healthcare. The best clinical teachers I had in medical school taught me that if I listened to my patients, they would tell me what was wrong with them. After many years of medical practice I know with certainty that no truer words were spoken. With the wealth of information on the web physicians and patients can work together as partners, a manner of practicing medicine that has very little down side.

To get back to Mr. Mumford, my vision for the future of medicine includes accepting what is new because it brings us back to what is old--taking care of the individual patient (the old) by utilizing the new (Electronic records and social media) and in the process creating partnerships with patients as well as other physicians and healthcare providers. This doesn't mean that my "partnered" patient will get the inappropriate antibiotic she insists is necessary. But it does mean that patients may once again see me as something other than a prescription supplier and test taker. Dialog is so much more satisfying than one-way conversation.