A * Readable * Usable * Patient Note

It's not just the clicks. It's creating a Readable.Usable.Note.[1][2] It is embarrassing to look at a patient chart and read: "Your HDL (good) cholesterol is excellent but your LDL (bad) cholesterol is too high. I would recommend trying to reduce sure fact food intake." What? Oh, yeah, reduce your fatty food intake. Or worse: "She wanted me to know that she had a laparoscopic hysterectomy and in for reck to me over the summer." That one took a while to figure out. What I dictated was "she had a laparoscopic hysterectomy and oopherectomy over the summer." Ouch. I read over my notes before I sign them but between the rush of seeing patients and the problem with editing your own notes within the horrible output that electronic records produce, it's easy to miss your own mistakes.

The notes are built to maximize the billing that we do. But frankly, even though I revisit a patient's chart and check their past medical history, update their meds, update their family history, review their social history, etc. IT DOESN'T NEED TO BE REPEATED IN THE NOTE! However, if I don't rewrite all that, Medicare or the insurance company doesn't believe I did it and I can't charge for it. As a consequence everything is repetitive and finding the little gem of information one needs to care for the patient becomes more and more difficult. As anyone who has ever received the reams and reams of paper from an ER with an electronic health record (EHR) that has no discernible font changes or indentation can tell you, it is next to impossible to determine why the patient was there, what treatment they received and what followup they need. 

To counteract this I dictate my medical reasoning in the discussion box at the end of the note. Next visit that's where to look to find the important stuff. Of course this increases the amount of time documenting, taking away more precious moments I have to spend with the patient creating inelegant notes that are one step away from being worthless for subsequent treatment.  

What if we could create two notes for every patient. One that went in to the billing records for auditing purposes and one culling the important stuff into a true "patient care note". Surely there is software that could help us with that.

To quote Dr. Vartabedian: What do you think?

1. We need to reassess the patient note. http://www.kevinmd.com/blog/2013/08/reassess-patient-note.html
2. The doctor will see your medical record now. http://www.slate.com/blogs/future_tense/2013/08/05/study_reveals_doctors_are_spending_even_less_time_with_patients.html

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!

Guest Blog: A Patient's EHR Point-of-View

Barry Comer, blogging at Thoughts/Rhythms, gives a poet's impression of the EHR experience:

In June of 1966, several crew members begin dying from a mysterious depletion of salt, extracted from their bodies. The crew’s doctor anaylizes post-mortum and discovers by instrument, the phenomenon’s cause. 

Of course this is the fiction in 1966, envisioned by Gene Roddenberry for the 23rd century. The imaginary “tricorder” in the doctor’s hands is for wishful dreamers and possibly envied by my physician, in 2012. 

With the introduction of electronic medical records (EMR) to the patient/physician dialog, neither the future nor a “diagnostician in a hand” have arrived. Clumsy to learn, intrusive in use, EMRs in form and function are short-reaching obstacles, that chart their course with manual input and uncertain results. 

Some tools in the 21st century disappoint and others appear with malice. Because EMRs are still untamed and newly minted, their usefulness arrives as a mixed blessing. 

They say, “time heals all”, but our relationship is in trial to stay in the moment.

My physician is intuitive, intelligent and listens carefully. She possesses a black belt

in medical counsel, that appears clairvoyant. Her holistic relationship to my body and mind is why I call her my doctor. The EMR pushes that trust backwards. It conspires to break her gaze from me and worse, has taken certainty of our relationship, into the “getting to  know you” process again.

Not only do I depend on her words, I put trust in her eyes. But when they stray, I feel the magic leave by the tiny keystrokes and space bar taps, filling the exam room. Our agreed upon relationship is breaking and hear it in her sigh.

This was not the future promised and feel once again, that some technologies are better left in clinical trial, with release contingent on both aesthetic and functionality. Without both, advancement seems muted by imagined giggling of software authors in the bushes. 

Not all things advanced by the goalkeepers make for better analysis and savings. Growing suspicious has been supplanted with hopeful resignation. It may get better and after all, 

I may just have a cold.    

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.

Docere

This morning I was watching a TED presentation by Dr. Jeff Benabio who was speaking about his vision of our profession's future. It was an interesting talk and I invite you to watch it but what struck me was the etymology of the word doctor. It comes from the Latin docere meaning "to teach". Ah, it's truly what I do all day long, with every patient. And perhaps that explains why primary care physicians have such low value in our society. After all, how well do we pay our teachers? If I was a proceduralist, a surgeon or interventional radiologist I'd be rolling in the big bucks. Maybe not as satisfied with my job, but hey, you can get satisfaction elsewhere when you make half a million bucks and year AND have three MONTHS of vacation!

Sorry, I digress...docere. This morning I explained the mediterranean diet to two individuals then recommended and demonstrated weight loss and exercise apps to them as well, listened to a woman talk about the sudden death of her husband last week (no education there, just listening), explained to my medical assistant why the prior authorization papers from the insurance company need to be put in the same spot in a 2" thick chart so next year when we have to reauthorize her medication we can find it, discussed the myriad of causes for iron-deficiency anemia to a daughter so her mom could understand in Hindi why a colonoscopy and endoscopy is necessary, described the use of "eustachian tube exercises" to a musician with allergies who is having hearing problems (and why they work), explained how and why MRSA is now a community-acquired disease instead of just from health-care facilities and discussed how a young woman's elevated blood pressure might be related to her increased use of NSAIDs. Wow, while I had this dim awareness of teaching, today was the first quantification of that in a typical morning and I am impressed. 

So it turns out that I really enjoy teaching, even though I would never have chosen it as a profession. Most of my patients are motivated to learn and want to make changes. While they may occasionally be resentful of what I tell them, most of them want to have healthier lifestyles and my middle class population has the economic wherewithal to hire a trainer, go to a gym, join Weight Watchers, etc. Slowly I'm incorporating tech in my educational tools--I routinely use my iPhone with patients, either looking up medications, treatments or diseases with ePocrates.

 My dream device would be an iPad, complete with anatomy apps that would give me an educational advantage while speaking with my patients. Someday, maybe....but my understanding, as we transition to electronic medical records (EMR), is that we will be stuck with a PC tablet and without the anatomy apps that make teaching so much more fun. Sigh.