The Irony of a Paper TOC Document in an EHR

Over one year ago my office implemented Allscripts Enterprise EHR (Electronic Health Record). I've not done a note on paper since. Last week, a "Transition of Care" (TOC) document was placed on my desk with a sticky note stating: "Dr. Nieder please fill out this form so we can bill a 99496 for your visit with Mrs. Jones yesterday". I pick up two sheets of paper with multiple questions including: 

• Discharge Medications: (list)
• Present Medications: (list)
• Diagnostic tests reviewed/disposition (list)
• Disease/illness education (discussion documentation)
• Home health/community services discussion/referrals: (list)
• Establishment or re-establishment of referral orders for community resources: (list)
• Discussion with other health care providers: (list)
• Assessment and support of treatment regimen adherence: (discussion documentation)
• Appointments coordinated with: (list)
• Education for self-management, independent living and activities of daily living: (discussion documentation)

Please remember, I am now on an EHR. So I am expected to document in the EHR and THEN fill out these forms. I have no discharge summary yet from the hospital. It may be ready but no one sent it to me and since our hospital is not sync'ed with our ambulatory clinics it didn't seamlessly flow into my patient's chart when she was discharged. When I finally do get it, there is no mention of any referrals given other than with the surgeon she saw in the hospital and me. The discharge medications state "resume pre-admission meds". In order for me to list what tests she had and make sure they are normal I have to return to the hospital portal and look them all up. Some of them have already been scanned into the EHR. I have no idea if there were other referrals made but I doubt it. She had a very straight-forward admission for a small bowel obstruction. She declined to keep the surgeon's appointment since they gave her instructions in her care in the hospital. I concurred about that. She could call them if she needed them. The women is a healthy 65-year-old who still works part-time as an accountant. She travels a lot. 

This TOC visit is paid at a much higher rate than other visits IF the patient does not return to the hospital in the next 30 days. Hence, we hold the billing until that time. 

My understanding of the purpose of this new code is to improve the CO-ORDINATION of care as the patient transitions from the hospital to home. Coordination would imply that there are other individuals involved in giving the patient care and thus we should have improved COMMUNICATION

between us. However, at least in my institution, my staff and I bear the brunt of gathering information (which is what we normally do anyway, so I guess it's nice because now we get paid for it). 

At what point will it become incumbent upon the hospital, who I work for, to send me the necessary information for treating the patient now that he/she is home again? How does it follow that improving care means the primary care doctor fills out even MORE FORMS ultimately reducing the time spent with the patient? At what point does the operability of two disparate systems (office EHR and hospital EHR) talk to each other and the information I need is already in the EHR? Why isn't all the information the patient needs sent home with her and she is told to bring that with her to her primary care doctor's visit which, oh by the way, should be done within two weeks? Why aren't all appointment made before she walks out the door? 

The form will not keep the patient out of the hospital. Communication will keep the patient out of the hospital. True coordination of care might keep the patient out of the hospital. More busy work for the patient's primary care doctor will not. Since the order of the day is using hospitalists (a discussion on that is a post for another day) it is imperative that we improve our communication systems at the time of discharge and before the patient is seen again in the primary care office. Systems must stop thinking that one more form is going to save the patient. Especially another form on my back.


This post's ending was rewritten on 10-10-2013 to take into account the multi-faceted reasons for the form.

Thoughts on MedX

This morning I sit in my daughter's San Francisco apartment pondering the barrage of information that I was exposed to during the previous three days at the Stanford MedX conference. My mind is full of images that begin with Regina Holliday's beautiful pre-conference canvas

Representation of a part of the canvas

and end with my friends Lisa Fields and Ruth Ann Crystal; relationships made over the internet through Social Media and cemented by meeting IRL (in real life).

Ruth Ann Crystal, myself, Lisa Fields

The conference was a showcase of healthcare innovation and opportunities to network with empowered patients from the Society for Participatory Medicine and other like-minded health professionals. The epatients' stories along with Regina Holliday's exhortations to "change the world NOW" were the most compelling part of the program. Over the next few weeks I hope my mind processes what was learned and results in more ideas for changes that improve patient experience in my practice and, who knows, even in my healthcare system.

Flash mob on stage with Regina Holliday (in red)

At first, when asked by other participants why I came to Stanford, I wasn't immediately sure. I made the reservation out of a gut reaction but by day two my motivation was obvious: MedX provides the energy and focus necessary to change our broken healthcare system. Tim Autrey of the Practicing Perfection Institute commented in his workshop that change must start with the individual. This individual began over a year ago but the MedX conference provided a powerful infusion of energy to improve my personal relationships with patients and exhort my system to do the same. Thank you Dr. Larry Chu, Nick Dawson and the staff who worked so hard to make the conference the success it has become.

Google Glass in Primary Care

Google Glass is in its infancy, with over 8000 "explorers" who are eager to find compelling uses for it. The concept is cool: A hands-free cell phone that is voice activated. A month ago my healthcare social media friend Kathi Browne, who is a Glass Explorer, proposed driving to Louisville from Knoxville to allow me to play with Glass for two days.

Kathi Browne's Google+ site

I was excited to accept her generous offer. She was equally accommodating about spending two days in my home which is presently a construction area with two cats, to which she is allergic. She seemed to tolerate the experience admirably.

As expected with a beta product, we had a few setbacks. We couldn't tether Glass to my iPhone unless I gave up my grandfathered unlimited data plan. That wasn't happening. Next we tried using the local network in my office. When that didn't work we thought we'd found an answer jumping on my MiFi. That was great until Glass went into sleep mode (which is frequent due to a short battery life) which disrupted the MiFi connection and I couldn't get it back online until the battery was taken out of the unit. It isn't easy to remove. Finally Kathi just handed me her phone and I stayed live on her account.

The main advantage over a regular smartphone is how surprisingly unobtrusive the device is, both to you and the patients. It's easy for the wearer to ignore it except when in use. Patients were of three varieties--too polite to ask what was on my head until I brought it up and then not caring, knowing immediately what it was and wanting to play with it, and being unaware of the product but excited to learn about it. No one appeared worried and the first thing I told them on entering the room was that it was not recording.

While it's easy to understand how surgeons, teaching physicians or ER personnel might use Glass, its implications in the primary care office are less clear. A few thoughts:

• Glass is much less obtrusive than the laptop I carry or even the chart I used to carry. If I could dictate into the EHR this could enhance communication with patients.
• Having a projection screen that would show the patient what I was looking at could be used for education, the way I sometimes use my iPad now. For instance, I had a patient with shingles on her back and I could project her rash or a reference rash for comparison. I can do that with my iPad now but that involves carrying an iPad and a laptop. I don't use the laptop for education because the screen is awful.
• On the down side, there is no unobtrusive way to Google a question using voice activation. My patients would know exactly how dumb I am. Wait, I already do that with them on the laptop so with Glass I could look cool and dumb. 
• In a rural setting, sending a picture or a video from the exam room to a specialist would be advantageous but no more than telemedicine could do.
• Calling up an examination video for something I don't do a lot of, like a specific orthopedic exam, could be helpful but I'm not sure about the patient's reaction. They usually prefer to think their doctor is well-versed in such things. Back to cool and dumb.
• It's quicker to Google with Glass, an advantage over a cell phone. 
• The voice recognition is amazing. Odd names and medical terms were usually nailed on the first try. However, there didn't seem to be a way to correct recognition mistakes.
• I suppose patients would get used to it, but would they worry that I was secretly recording them?
• As Clive Thompson commented in today's New York Times[1], using Glass is uncomfortable enough that constantly looking at the little screen is not an option. That could improve communicating time instead of the way the EHR takes away from it. 
• How about an app in Glass that would identify a rash within certain parameters of likelihood? That is, a Watson for Glass. This was also suggested by Melissa McCormack of Software Advice in the Profitable Practice blog.

What I enjoyed most was the shear delight of several patients who wore it for a few moments. They were so excited by the device and its possibilities. Whether it will prove of use in the everyday practice of the primary care doctor remains to be seen.

1. Googling Yourself Takes on a Whole New Meaning http://goo.gl/WAAWki 


Post was edited 9-4-2013 by request of Ms. McCormack to better describe her blog.